THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


Gift   of 
Dr.  v;.   L,   Grant 


^x3  ^^^ 


Digitized  by  tine  Internet  Arciiive 

in  2007  witii  funding  from 

IVIicrosoft  Corporation 


littp://www.arcliive.org/details/diseasesofcliildrOOracliiala 


DISEASES  OF  CHILDREN 


DISEASES 
OF  CHILDREN 

A    PRACTICAL    TREATISE    ON    DIAGNOSIS    AND 

TREATMENT   FOR  THE    USE    OF  STUDENTS 

AND   PRACTITIONERS  OF  MEDICINE 


BY 

BENJAMIN   KNOX   RACHFORD 

PROFESSOR   OF    niSKASKS   OK   CHII.DRKV,  OHIO-MIAMI    MEDICAL   COLLEGE,   DEPARTMENT    OK   MEDICINE   OK    THE 

UNIVERSITY  OF   CINCINNATI:    PEDIATRICIAN   TO   THE    CINCINNATI    HOSPITAL.    GOOD    SAMARITAN 

HOSPITAL    AND    JEWISH    HOSPITAL;     EX-PRESIDENT    OF    THE    AMERICAN    PEDIATRIC 

SOCIETT  AND   MEMBER  OF  THE  ASSOCIATION  OF   AMERICAN   PHYSICIANS. 


NEW  YORK    AND    LONDON 
D.    APPLETON    AND    COMPANY 

1912 


Copyright,  1912,  bt 
D.  APPLETON    AND    COMPANY 


Printed  in  the  United  States  of  America 


BMmctietl 

Umr 


|0O 


TO 

MY  WIFE, 

WHO    HELPED    ME    WRITE    THIS    BOOK 


Gorans 


PREFACE 

In  this  volume  the  author  has  attempted  to  present  to  practitioners  and 
students  of  medicine  a  practical  clinical  treatise  on  diseases  of  infants  and 
children.  He  has  but  briefly  outlined  the  pathological  findings  and  has 
avoided  unnecessary  etiological  discussions  in  order  that  he  might,  in  a 
compact  volume,  find  more  space  in  which  to  clearly  outline  the  differential 
diagnosis  and  give  in  full  the  treatment  of  these  diseases. 

The  diseases  of  infancy  and  childhood  differ  very  widely  in  their 
clinical  manifestations  and  in  the  methods  of  their  successful  treatment 
from  corresjjonding  diseases  in  the  adult;  the  reasons  for  this  are  physio- 
logical rather  than  pathological.  The  undeveloped  organism  of  the  child, 
because  of  its  physiological  peculiarities,  reacts  to  the  same  pathological 
factors  very  differently  from  the  completed  and  stable  organism  of  the 
adult.  For  this  reason  the  author  has  dwelt  in  detail  on  the  physiological 
factors  of  disease  in  infancy  and  childhood,  and  has  attempted  to  make 
practical  application  of  these  facts  both  in  the  prophylactic  and  curative 
treatment  of  these  diseases. 

The  author  acknowledges  his  indebtedness  to  Gen.  Wm.  M.  Wherry, 
Dr.  M.  A.  Brown,  Dr.  Alfred  Friedlander,  Dr.  David  I.  Wolfstein,  Dr. 
Max  Dreyfoos,  Dr.  Frank  H.  Lamb,  Dr.  M.  L.  Heidingsfeld,  and  Dr. 
Samuel  Iglauer  for  revision  of  manuscript,  and  to  Dr.  W.  J.  Graf  for 
photographic  work. 

323  Broadway,  Cincinnati. 


CONTENTS 

SECTION  I 
THE  CHILD 

I  PAGB 

I.     General  Hygiene  of  Infancy  and  Childhood        .        .  1 

Chief  causes  of  death  in  infancy  and  childhood;  gen- 
eral hygiene  and  care  of  infants  and  young  children. 

II.    Growth   and   Development 13 

Weight  during  infancy  and  early  childhood;  height  of 
child  at  different  ages;  head  measurements;  develop- 
ment of  the  spine  and  bony  framework;  muscular  de- 
velopment; the  special  senses;  the  nervous  system;  the 
heat-regulating  mechanism. 

III.  Examination  of  the  Sick  Child      .        .        .        .        .        28 

Present  illness;  previous  medical  history;  family  his- 
tory; physical  examination;  inspection;  palpation;  re- 
flexes; percussion;  auscultation;  macroscopic  and 
microscopic  examination  of  intestinal  discharges; 
tuberculin  skin  reactions;  blood  examinations;  lumbar 
puncture;  radiography. 

IV.  Therapeutics  op  Infancy  and  Childhood        ...        38 

Drug  administration  by  the  mouth;  inunctions;  fresh 
air;  hydrotherapy;  hypodermoclysis ;  nasal  douche; 
stomach-washing;  rectal  enemata;  rest-cure;  massage; 
active  and  passive  exercises;  psychotherapy;  vaccine 
therapy. 

SECTION  II 

THE  NEW-BORN 

V.     The  Care  of  Premature  Infants 62 

Physiological  peculiarities  of  the  new-born;  incubator; 
padded  basket;  feeding. 

VI.    Diseases  of  the  New-Born 69 

Asphyxia  neonatorum;  congenital  atelectasis. 
VII.    Diseases  op  the  New-Born  (Continued)  ...        75 

Septic    infection;    dermatitis    exfoliativa;    erysipelas; 
ix 


CONTENTS 

lAPTEB  PAGE 

hemorrhages  in  the  new-born;  diseases  of  the  umbili- 
cus; mastitis;  Holt's  inanition  fever. 
VIII.    Diseases  of  the  New-Bobn   (Continued)  .        .        .        89 

Tetanus  neonatorum;  icterus  neonatorum;  occlusion  of 
the  bile  ducts  in  the  new-born;  other  forms  of  icterus 
occurring  in  the  new-born;  ophthalmia  neonatorum. 

IX.     Birth   Injuries  97 

Cephalhematoma;  hematoma;  birth  palsies. 


SECTION  III 

INFANT  FEEDING 

X.    Milk  in  Its  Relation  to  Infantile  Nutrition        .        .      100 
Composition;  digestibility,  and  relative  importance  of 
the  various  ingi-edients  of  milk. 
XI.    Human    Breast    Milk    in    Its    Relations    to    Infant 

Feeding 107 

Composition  of  colostrum  and  human  milk;  how  to 
determine  wholesomeness  of  breast  milk;  how  to 
modify  its  quantity  and  quality. 

XII.    Breast-Feeding 112 

Principles  underlying  normal  breast-feeding;  mixed 
feeding;  weaning;  the  wet-nurse. 

XIII.  Food    Materials    Used   in    the    Artificial   Feeding   of 

Infants 118 

Clean  raw  cow's  milk;  sterilized  milk;  pasteurized 
milk;  peptonized  milk;  buttermilk;  Finkelstein's  al- 
bumin milk;  skim  milk;  whey;  carbohydrates;  pro- 
prietary foods;  albumin  water;  meat  preparations. 

XIV.  Artificial  Feeding 129 

Value  of  percentage  feeding;  calorimetric  standard; 
principles  underlying  artificial  feeding;  home  modifi- 
cation of  milk;  value  of  carbohydrate  and  alkaline 
diluents;  feeding  of  difficult  cases;  laboratory  method 
of  modifying  milk;  diet  of  children  as  they  grow  older. 

SECTION  IV 
DISEASES  OF  THE  DIGESTIVE  SYSTEM 

XV.    Dentition 144 

The  eruption  of  the  temporary  teeth;  dentition  as  a 
pathological  factor;  permanent  teeth. 


CONTENTS 


XI 


CHAPTER 

XVI. 


XVII. 


XVIII. 


XIX. 
XX. 

XXL 
XXII. 

XXIII. 
XXIV. 

XXV. 

XXVI. 

XXVII. 

XXVIII. 


PAOK 

Stomatitis 146 

Stomatitis  catarrhalis;  stomatitis  aphthosa;  stomatitis 
mycosa;   stomatitis   ulcerosa;   stomatitis   gangrenosa. 

Other   Diseases   of  the  Mouth   and   Diseases  op   the 

Esophagus  154 

Bednar's  aphthae;  perleche;  elongated  uvula;  geo- 
graphical tongue;  tongue-tie;  hare-lip;  esophagitis; 
periesophageal  abscess;  branchial  cysts. 

Diseases    of    the    Stomach 158 

Acute  gastric  indigestion;  acute  gastritis;  dilatation 
of  the  stomach;  ulcer  of  the  stomach;  acute  gastroduo- 
denitis;  congenital  hypertrophy  of  the  pylorus; 
chronic  gastritis. 

Etiology  and  Preventive  Treatment  of  the  Intestinal 

Disorders  of  Infancy 173 

Acute  Intestinal  Indigestion 183 

Food  injuries;  fat  indigestion;  sugar  indigestion; 
protein  indigestion. 

Enteric  Infection 189 

Acute  enterocolitis;  cholera  infantum. 

Chronic  Intestinal  Indigestion 197 

Chronic  enterocolitis;  infantile  atrophy;  marasmus; 
chronic  intestinal  indigestion  in  older  children. 

Chronic  Constipation  in  Infancy  and  Congenital  Dila- 
tation OF  the  Colon 204 

Intestinal    Parasites 210 

Tape-worms;   round-worms;   thread-worms. 

Intestinal  Intussusception 219 

Appendicitis 222 

Peritonitis  and  Ascites 228 

The  Rectum  and  the  Anus 233 

Malformations;  polypi;  prolapse;  fissure  of  anus. 


SECTION  V 


NUTRITIONAL  DISORDERS 


XXIX.    Rickets 237 

XXX.     Infantile   Scurvtt 246 

XXXI.     Diabetes   Mellitus 250 

XXXII.    Recurrent  Vomiting,  Recurrent  Coryza  and  Migraine  251 
Severe    acid    intoxication    with    gastroenteritis;    recur- 
rent coryza;  migraine. 


xu 


CONTENTS 


SECTION  VI 
INFECTIOUS  DISEASES 

CBAFTEB  PAQB 

XXXIII.  Fever              260 

XXXIV.  Typhoid   Fever 267 

XXXV.     Malaria 279 

XXXVI.    Whooping   Cough 287 

XXXVII.    Diphtheria             295 

XXXVIII.     Influenza              308 

XXXIX.     Scarlet  Fever 315 

XL.    Measles 332 

Rubella,  erythema  infeetiosuni. 

XLI.     Variola           . 345 

Vaccinia ;  vaiicella. 

XLII.    Mumps            357 

XLIII.     Syphilis 360 

XLIV.     Tuberculosis 373 

XLV.    Acute    Articular    Rheumatism    and    Other    Forms    of 

Arthritis 402 


SECTION  VII 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 


XLVI.    Diseases  of  the  Nasal  Mucous  Membrane      .        .        .      411 
Rhinitis;  epistaxis;  foreign  bodies  in  the  nose. 

XLVIL    Diseases  of  Tonsils 417 

Acute  follicular  tonsillitis;  Vincent's  an^fina;  chronic 
tonsillar  hypertrophy;  quinsy. 

XLVIII.    Diseases   of   Pharynx 424 

Adenoids;  acute  retropharyngeal  abscess. 

XLIX.    Diseases  of  Larynx 429 

Acutd^  lai'yngitis ;  edema  of  the  laiynx;  growths  and 
foreign  bodies  in  the  larynx;  congenital  laryngeal 
stridor. 

L.    Bronchitis  438 

Acute  catarrhal  bronchitis;  chronic  bronchitis;  mem- 
branous bronchitis. 

LI.    Lobar  Pneumonia 442 

LII.    Bronchopneumonia 454 

LIII.    Pleurisy 470 


CONTENTS 


xui 


SECTION  VIII 
THE  HEART 

CHAPTEB  PAGE 

LIV.    Congenital   Heakt   Disease 484 

LV.     Acute   Endocarditis              489 

LVI.    Myocarditis  and  Acute  Cardiac  Dilatation    .        ,        .  494 

LVII.     Chronic  Valvular  Disease 498 

LVIII.    Functional   Cardiac   Disorders 506 

LIX.    Pericarditis            509 


SECTION  IX 

DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS 

LX.    The   Blood .        .        .515 

LXI.     Simple   Secondary  Anemia 522 

LXII.    Pseudo-Leukemia  op  Infants     .        .        .        .        .        .  524 

LXIIL    Chlorosis               526 

LXIV.    Pernicious    Anemia 528 

LXV.    Leukemia 530 

LXVL    Purpura             531 

LXVII.    Hemophilia            537 

LXVIIL    HoDGKiN's  Disease 540 

LXIX.    Simple   Adenitis 542 

LXX.     Status  Lymphaticus            545 

LXXI.    Diseases  op  the  Spleen 551 

LXXII.    Diseases  of  the  Thyroid  Gland 552 

Sporadic  cretinism. 


SECTION  X 
DISEASES  OF  THE  UROGENITAL  SYSTEM 

LXXIIL     The  Urine     .    -^ ^— - 

Lithuria;     indicanuria;     hematuria;     hemoglobinuria; 

acetonuria;      physiological      albuminuria;      orthostatic 

albuminuria. 

LXXIV.    Acute  Nephritis 

LXXV.    Chronic  Nephritis  and  Other  Diseases  of  the  Kidneys 

Chronic  diffuse  nephritis;,  cystopyelitis ;  tumoi-s  of  the 

kidney;    hydronephrosis;   perinephritis;   dislocation   of 

the  kidney. 


559 


571 

582 


XIV 


CHAPTER 

LXXVI. 


CONTENTS 


Diseases  of  the  Genital  Organs      .... 
Gonorrheal      vulvovaginitis;      simple      vulvovaginitis; 
urethritis;  adherent  prepuce;   phimosis;   periphimosis ; 
undescended  testicle;  hypospadias;  enuresis. 

LXXVII.      PSEUDOMASTUKBATION     IN     INFANTS  .... 


PAOE 

591 


603 


SECTION  XI 


DISEASES  OF  THE  NERVOUS  SYSTEM 

LXXVIII.    Diseases  of  the  Brain 610 

Infantile  cerebral  palsies;  brain  tumoi's;  abscess  of 
the  brain ;  chronic  internal  hydrocephalus ;  meningo- 
cele; encephalocele ;  hydrencephalocele ;  idiocy. 

LXXIX.    Meningitis  626 

Tuberculous  meningitis;  meningococcus  meningitis; 
purulent  meningitis. 

LXXX.    Diseases  of  the  Spinal  Cord 641 

Anterior  poliomyelitis;  myelitis;  hereditary  ataxia; 
spina  bifida. 

LXXXI.    Diseases  of  Peripheral  Nerves 661 

Multiple  neuritis;  facial  paralysis;  progressive  mus- 
cular dystrophy. 

LXXXII.     General  Nervous  Diseases 669 

Disorders  of  sleep ;  eclampsia  in  infants  and  children ; 
laryngismus  stridulus;  tetany  in  infancy  and  child- 
hood; nystagmus;  epilepsy;  chorea;  habit-spasm; 
pica;  hysteria;  headaches;  asthma. 


SECTION  XII 
DISEASES  OF  THE  EAR 
LXXXIII.    Otitis  Media  and  Mastoiditis    . 


714 


SECTION  XIII 

DISEASES  OF  THE  SKIN 

LXXXIV.     Eczema  and  Other  Skin  Diseases    .... 

Eczema;  urticaria;  f  urunculosis ;  erythema  multi- 
forme; congenital  icthyosis;  impetigo  contagiosa; 
pemphigus  neonatorum;  tinea  tonsurans;  scabies; 
pediculosis  capillitii. 


719 


LIST   OF    ILLUSTRATIONS 


PLATES 

PLATE  _  _  FACING  PAGE 

1.     The  Moro  tuberculin  skin  reaction 36 

II.     Blood  picture  in   dermatitis   exfoliativa 79 

III.  The  enanthem  of  measles   (Koplik's  spots) 335 

IV.  The  von  Pirquet  tuberculin  skin  reaction 385 

V.     Scheme  of  the  circulation  of  the  blood  in  the  fetus 483 

VI.     Blood    pictures    in     von    Jakseh's    disease,    and    acute    lymphatic 

leukemia    525 


ILLUSTRATIONS   IN  THE  TEXT 

FIOmtB  PAGB 

1.  Effect  of  electrical  stimulation  on  the  spinal  ganglion  of  cat 12 

2.  The  rate  of  growth   in   weight  of   dull,   mediocre,   and    precocious 

boys   and  girls 16 

3.  Bad  position  while  writing 20,  21 

4.  Palpating   spinal   curvature 32 

5.  Percussion  and   auscultation  position 33 

6.  Position   for  lumbar  puncture 37 

7.  Fresh-air  ward    44 

8.  Hypodermoclysis    47 

9.  Position  for  nasal  douching 48 

10.  Stomach-washing    50 

11.  Tempei'ature  curve  showing  influence  of  artificial  heat  on   prema- 

ture  infant    63 

12.  Padded  basket  for  treatment  of  premature  infants 67 

13.  Breck's  feeding-tube    68 

14.  Schultze's  method   of  artificial  respiration 72 

15.  Blood  chart  in   dermatitis  exfoliativa 79 

10.     Umbilical   hernia    86 

17.  Colostrum    108 

18.  Woman's   milk    108 

19.  Weight   chart   breast-fed   infant 114 

20.  Freeman's   pasteurizer    121 

21.  Weight  chart  artificially  fed   infant 136 

22.  Thrush   fungus    149 

23.  Stomatitis   gangrenosa,    before    perforation 152 

XV 


xvi  LIST    OF    ILLUSTEATIONS 

PAGE 
FIODRB  , 

24.  Sloniatitis   sraiijirenosa,   after   perforation lo'^ 

25.  Radiograph,    i»yloric    stenosis 16<3 

26.  Congenital  stenosis  of  tiie   pylorus 167 

27.  Congenital    stenosis    of   the    pylorus,    longitudinal    section    through 

tumor   mass    l"*^ 

28.  Temperature  chart,  gastroenteric  infection,  mild 189 

29.  Temperature  chart,  gastroenteric  infection,  severe 190 

30.  Casein   curds    198 

31.  Infantile    atrophy    199 

32.  Taenia   saginata    211 

33.  Taenia  solium    212 

34.  Ascaris   lumbricoides    216 

35.  Egg  of  ascaris  lumbricoides 216 

36.  Oxyuris  vermicularis    218 

37.  Acute  peritonitis   position 230 

38.  Malformations   of  the   rectum 233 

39.  Radiograph  showing  bony  deformities  in  rickets 238 

40.  A  case  of  rickets 239 

41.  Knock-knees  and  bow-legs 241 

42.  Temperature  chart,  typhoid  fever,  child  2Y2  years  of  age 270 

43.  Temperature  chart,  typhoid  fever,  child  6  years  of  age 271 

44.  Temperature  chart,  typhoid  fever,  child  10  years  of  age 272 

45.  Temperature  chart,  typhoid  fever  with  relapses.. 274 

46.  Temperature   chart,    malarial   fever 282 

47.  Temperature  chart,  pertussis  and  measles  complicated  by  broncho- 

pneumonia    290 

48.  Temperature  chart,  pharyngeal  diphtheria  treated  with  antitoxin..  297 

49.  Temperature  chart,  laryngeal  diphtheria  treated  by  intubation ....  298 

50.  Chart  showing  decreased  death  rate  from  diphtheria  under  antitoxin  303 

51.  Intubation    position    306 

52.  Temperature  chart,  scarlet  fever,  mild,  child  12  years  of  age 319 

53.  Temperature  chart,  scarlet  fever,  severe,  child  6  years  of  age 320 

54.  Chart  showing  mortality  by  age  in  5,000  eases  of  scarlet  fever. . .  .  326 

55.  Temperature    chart,    measles,    uncomplicated 336 

56.  Temperature    chart,    measles,    complicated    by    bronchopneumonia; 

died 337 

57.  Temperature    chart,    measles,    complicated    by    bronchopneumonia; 

recovered 338 

58.  Varicella  eruption  on  the  fourth  day 355 

59.  Syphilitic   dactylitis    365 

60.  "Hutchinson's   teeth" 366 

61.  Bronchial  and  other  lymph  nodes  mainly  affected  in  tuberculosis. .  379 

62.  Radiograph,  enlarged  bronchial  glands  at  right  hilum 380 

63.  Pulmonary  tuberculosis  with  left-sided   pneumothorax 389 

64.  Ileopelvie   lymphatic   glands 390 


LIST    OF    ILLUSTRATIONS  xvii 


PAGE 


65.  Anterior  view  of  the  cecum  and  appendix 391 

66.  Tuberculosis  of  the  spine 392 

67.  Position  in  examination  for  adenoid  growths 427 

68.  Retropharyngeal    lymph    glands 428 

69.  RadiogTaph  of  foreign  body  in  right  bronchus 436 

70.  Temperature  chart,  lobar  pneumonia,  child  2  years  of  age 445 

71.  Temperature  chart,  lobar  pneiunonia,  child  4  years  of  age 446 

72.  Temperature  chart,  lobar  pneumonia,  child  10  years  of  age 447 

73.  Temperature  chart,   bronchopneumonia,  mild 459 

74.  Temperature  chart,  bronchopneumonia,   severe 460 

75.  Temperature  chart,  empyema  following  pneumonia 473 

76.  Temperature   chart,   empyema 474 

77.  Radiograph,  pleural  effusion  in  chest 476 

78.  James'  apparatus  for  expanding  the  lung. 481 

79.  Clubbing  of  the  fingers  in  congenital  heart  disease 486 

80.  Radiograph  of  enlarged  heart  from  mitral  regurgitation 500 

81.  Radiograph  of  pericarditis  with  effusion 511 

82.  Diagram  showing  blood  changes  in  a  case  of  purpura  hemorrhagica  534 

83.  Position  in  palpating  the  spleen 551 

84.  Typical  cretin,  age  4  years 554 

85.  Same  cretin  after  eight  years  of  treatment 555 

86.  Sarcoma  of  the  kidney 588 

87.  Genitourinaiy  organs,  embryo  about  five  weeks , 604 

88.  Genitourinary  organs,   embryo  about  nine  weeks 605 

89.  Genitourinary    organs    606 

90.  Hemiplegia  from  cerebral   hemorrhage 612 

91.  Spastic   diplegia    •  •  614 

92.  Idiopathic  hydrocephalus    619 

93.  Meningocele,    encephaloeele,    hydrencephalocele 621 

94.  Temperature  chart,  tuberculous  meningitis 629 

95.  Opisthotonos    633 

96.  Temperature  chart,  meningococcus  meningitis 634 

97.  Temperature  chart,   pneumocoecus  meningitis 640 

98.  Temperature  chart,  acute  anterior  poliomyelitis 646 

99.  Deformities  resulting  from  acute  anterior  poliomyelitis 647 

100.  Quadrupedal  gait  from  acute  anterior  poliomyelitis 648 

101.  Hydrencephalocele  and  spina  bifida. 659 

102.  Progressive  muscular  dystrophy   667 

103.  Progressive    muscular   dystrophy 668 

104.  Progressive   muscular   dystrophy 669 

105.  Impetigo    contagiosa    731 

106.  Ringwonu  of  the  scalp 733 

107.  Pustular  scabies  of  the  hands 736 


PEDIATRICS 

SECTION  I 
THE    CHILD 

CHAPTER  I 

GENEEAL   HYGIENE   OF   INFANCY   AND   CHILDHOOD 

CHIEF  CAUSES  OP  DEATH     IN  INFANCY  AND  CHILDHOOD 

The  importance  of  the  proper  care  of  infants  and  young  children  is 
emphasized  by  the  terrible  mortality  which  occurs  during  the  early  months 
and  years  of  life,  and  by  the  fact  that  this  mortality  is  to  a  large  extent 
due  to  remediable  causes  pertaining  to  general  hygiene.  Only  a  few  years 
ago  it  was  estimated  that  about  25  per  cent,  of  all  infants  living  in  the 
large  cities  of  the  world  died  during  the  first  year  of  life,  and  of  these 
deaths  from  20  to  25  per  cent,  occurred  during  the  first  month  of  life. 
After  the  first  month  there  is  a  sudden  fall  in  the  death  rate,  and  there- 
after it  slowly  decreases  throughout  the  year.  The  mortality  after  the  first 
year  of  life  continues  high,  but  gradually  diminishes  up  to  the  fifth  year 
of  life.  At  this  period  there  is  a  second  rapid  fall  in  the  death  rate,  but 
the  mortality  is  still  high  as  compared  with  that  of  the  young  adult  and 
is  gradually  reduced  up  to  the  fifteenth  year. 

Holt  says:  "The  fundamental  causes  of  infant  mortality  are  mainly 
the  result  of  three  conditions,  poverty,  ignorance  and  neglect.'*  It  is  a 
matter  of  common  observation  that  the  great  death  rate  among  infants 
in  our  large  cities  occurs  largely  among  the  very  poor.  Among  the  well- 
to-do  classes  the  infant  mortality  is  comparatively  slight. 

The  chief  causes  of  death  during  the  first  year  of  life  are  prematurity, 
congenital  debility  from  hereditary  causes  (syphilis,  etc.),  malformations, 
birth  injuries,  septic  infection,  whooping  cough,  gastrointestinal  and  acute 
respiratory  diseases.  It  is  evident  that  a  certain  proportion  of  these  deaths, 
especially  those  due  to  prematurity,  congenital  debility,  malformations  and 
birth  injuries,  cannot  be  prevented,  and  yet  the  loss  of  life  from  these 
causes  could  be  materially  diminished  by  the  proper  medical  care  of  the 
mother  before,  and  of  the  infant  directly  after  delivery.  The  mortality 
from  septic  infection  and  gastrointestinal  diseases  has  been  very  materially 

1 


2      GENERAL  HYGIENE  OF  INFANCY  AND  CHILDHOOD 

diminished  in  recent  years  by  the  improved  hygienic  methods  for  the  care 
of  the  new-born. 

Between  the  end  of  the  first  and  the  sixteenth  month  of  life  the  high 
infantile  mortality  is  largely  kept  up  by  gastrointestinal  diseases,  which 
could  to  a  large  degree  be  prevented  if  it  were  possible  to  give  these  un- 
fortunate infants  suitable  food  and  place  them  under  better  hygienic  sur- 
roundings. 

After  the  end  of  the  first  year  of  life,  gastrointestinal  disorders  still 
play  an  important  part  in  producing  the  death  roll;  but  from  the  end  of 
the  first  to  the  fifth  year  of  life  influenza,  bronchitis,  and  the  pneumonias 
are  the  most  important  factors  in  keeping  up  the  high  death  rate.  These 
infectious  respiratory  diseases  are  largely  air-borne  and  are  promoted  by 
overcrowding  and  unhygienic  surroundings.  They  could  therefore  in  great 
part  be  prevented  if  infants  and  young  children  could  be  separated  from 
contagion  and  given  pure  flowing  air  to  breathe. 

After  the  fifth  year  the  ordinary  acute  infections,  such  as  scarlet  fever, 
diphtheria,  measles,  and  whooping  cough,  keep  the  mortality  of  later  child- 
hood higher  than  that  of  adult  life.  These  diseases  are  also  very  much 
more  prevalent  in  the  unhygienic,  crowded  tenements  of  the  poor  than 
among  the  larger,  well-ventilated  homes  of  the  middle  and  upper  classes. 
The  mortality  at  this  time  of  life  could  therefore  be  very  materially  dimin- 
ished by  improving  the  facilities  for  the  care  and  isolation  of  children 
suffering  from  these  infectious  diseases. 

The  fact  that  the  great  majority  of  deaths  which  occur  among  infants 
and  young  children  could  be  prevented  by  suitable  food,  proper  care,  whole- 
some surroundings  and  protection  from  contagions  has  stimulated  city 
health  boards  and  co-operating  philanthropical  societies  to  attempt  to  apply 
these  life-saving  measures  to  the  children  of  the  poor  in  our  large  cities 
and  as  a  result  of  these  efforts  infantile  mortality  has  been  reduced  from 
26  to  15  per  cent.,  and  the  mortality  among  children  under  five  years  of 
age  has  been  reduced  from  16  to  6  per  cent.  This  remarkable  showing  of 
the  influence  which  modern  hygienic  methods  have  had  upon  the  saving  of 
life  should  stimulate  and  encourage  to  still  greater  accomplishments  all 
those  interested  in  this  great  work. 

GENERAL  HYGIENE  AND  CARE  OF  INFANTS  AND 
CHILDREN 

Care  of  the  New-Born.— From  what  has  been  .said  it  is  evident  that 
one  of  the  most  important  duties  of  the  physician  is  to  keep  children  well, 
and  this  brings  us  to  the  consideration  of  the  general  hygiene  of  infancy 
and  childhood. 

Soon  after  birth  the  umbilical  cord,  when  the  pulsation  has  ceased, 
should  be  firmly  tied  with  a  piece  of  clean,  narrow  tape  and  then  cut  with 
clean  scissors.  Following  this  operation  the  infant's  mouth  should  be 
washed  out  and   its  breathing  and  heart  action  carefully  observed.     If 


CARE  OF  INFANTS  AND  CHILDREN  3 

these  be  normal  and  the  infant  has  cried  lustily,  indicating  that  normal 
pulmonary  inflation  has  begun,  it  may  be  wrapped  for  a  few  minutes  in 
warm  flannels,  until  the  nurse  who  is  attending  the  mother  has  the  time 
to  bathe  it.  The  body  of  the  infant  should  be  gently  rubbed  with  vaselin 
or  olive  oil  to  remove  the  vernix  caseosa  which  covers  its  body.  It  should 
then  be  placed  in  warm  water  (temperature  100°  F.)  and  gently  washed 
with  some  non-irritating  soap.  The  stump  of  the  cord  should  be  carefully 
dried  and  the  surrounding  parts  dusted  with  talcum  or  some  other  powder ; 
it  should  then  be  folded  in  a  pad  of  sterile  gauze.  This  may  be  done  by 
making  an  opening  in  the  pad  through  which  the  cord  is  inserted.  There- 
after it  is  important  to  keep  the  cord,  and  the  dressing  which  covers  it,  dry 
until  mummification  and  separation  take  place;  this  usually  occurs  about 
the  end  of  the  first  week.  Following  the  separation  of  the  cord  the  umbilicus 
for  a  few  days  presents  a  slightly  red  surface,  over  which  the  epithelium 
is  rapidly  forming.  By  the  end  of  the  second  week  the  umbilical  wound 
should  be  entirely  covered  with  epithelium  and  should  therefore  no  longer 
offer  a  favorable  portal  for  septic  infections.  Until  this  occurs  the  infant 
is  to  be  given  one  or  more  sponge  baths  every  day,  care  being  taken  through- 
out the  whole  time  to  protect  the  umbilical  wound  from  the  wash  water  or 
other  possible  sources  of  infection.  When  the  umbilical  wound  has  healed 
the  infant  is  to  have  a  tub  bath  daily,  beginning  with  a  temperature  of 
100°  F.,  gradually  diminishing  the  temperature  of  the  water  as  the  child 
grows  older,  but  during  the  first  year  of  life  it  is  not  advisable  that  the 
temperature  of  this  bath  should  fall  much  below  90°  F.  During  the  early 
days  of  the  life  of  the  infant  it  is  important  that  the  region  of  the  um- 
bilicus be  examined  without  removing  the  dressing  which  holds  the  mum- 
mifying cord.  A  certain  amount  of  redness  in  this  region  is  normal,  but 
if  the  parts  become  swollen,  or  if  the  odor  from  the  cord  becomes  putrid,  and 
especially  if  the  temperature  of  the  infant  rises  two  or  three  degrees  above 
normal  without  apparent  cause,  the  dressing  which  covers  the  stump  of  the 
cord  is  to  be  carefully. removed  and  evidences  of  sepsis  looked  for.  In  the 
event  that  the  umbilical  wound  becomes  infected,  it  is  to  be  treated  by  the 
method  described  in  the  chapter  on  Sepsis  in  the  New-Born. 

In  private  practice  it  is,  as  a  rule,  only  necessary  to  carefully  wash  out 
the  eyes  of  the  newly-born  infant  with  distilled  water,  or  a  3  to  5  per  cent, 
boracic  acid  solution.  But  in  the  event  that  the  mother  has  a  vaginal  dis- 
charge or  the  child  is  born  in  a  public  institution,  it  is  advisable  to  instil 
into  its  eyes  a  2  per  cent,  solution  of  nitrate  of  silver  and  thereafter  care- 
fully wash  them  out  with  sterile  water.  During  the  first  days  of  life  it  is 
important,  especially  if  the  infant  be  irritable,  to  have  its  rectal  tempera- 
ture taken  twice  a  day  with  a  clean^tliermometer  anointed  with  clean 
vaselin.  A  sharp  elevation  of  temperature  during  the  first  days  of  life 
suggests  either  sepsis  or  Holt's  (inanition)  fever.  It  is  most  important 
during  the  first  days  of  life  to  note  the  discharges  from  the  gastrointestinal 
canal.  The  diapers  containing  these  discharges  should  be  saved  for  the 
inspection  of  the  physician,  as  no  one,  not  even  a  trained  nurse,  can  ac- 


4      (iEXKHAL  HYGIENE   OF  INFANCY  AND   CHILDHOOD 

curatdv  convey  to  the  physician  their  character.  The  early  dark  meconium 
discharges  slmuld  comn.ence  to  give  way  on  the  third  day  to  milk  stools, 
and  witliin  ten  days  or  two  weeks  the  fecal  discharge  should  he  gradually 
transformed  into  a  soft,  yellow,  homogeneous  mass.  The  appearance  of 
dark,  tarry  stools  after  the  fifth  day  is  an  indication  of  intestinal  hemor- 
rhage (melena),  and  the  presence  of  mucus,  curds  and  other  ahnormalities 
may  he  important  early  indications  of  an  intestinal  condition  which  needs 

attention.  n   ■,      .•         u  • 

Rest  and  Sleep.— The  new-born  should  sleep  nearly  all  the  time,  being 
awake  but  two  or  three  hours  in  the  twenty-four.  A  young  infant,  there- 
fore that  spends  much  of  its  time  awake,  fretting  and  crying,  is  suffering 
from  some  condition  which  should  be  corrected;  hunger,  overfeeding  and 
indigestion  are  common  causes  of  fretfulness.  As  the  infant  grows  older 
it  is  awake  for  longer  periods  of  time,  but  even  at  one  year  of  age  it  should 
sleep  sixteen  hours  out  of  the  twenty-four.  It  is  most  important  during 
its  waking  hours  that  the  infant  should  not  be  coddled  and  played  with. 
It  is  a  very  difficult  matter  to  enforce  this  rule.  Most  infants  in  the  middle 
and  upper  walks  of  life  are  so  surrounded  by  doting  relatives  that  it  is 
difficult  to  protect  them  from  the  incessant  fondling  and  entertaining 
which  these  devoted  and  well-meaning  people  force  upon  them.  As  North- 
rup  has  so  graphically  pointed  out,  this  is  one  of  the  most  common  causes 
of  sleeplessness,  irritability  and  nervousness  in  infants.  For  the  good 
health  and  normal  development  of  the  infant  it  should  be  let  alone  during 
its  waking  hours.  Properly  trained  babies  are  perfectly  happy  and  will 
coo,  and  play  with  their  toes  or  some  other  object  which  they  happen  to 
find,  never  knowing  what  it  means  to  be  taken  up,  dandled,  coddled  and 
entertained. 

Fresh  Air. — When,  after  a  few  weeks,  the  infant's  nutritional  problems 
have  been  solved  and  its  heat  regulating  apparatus  has  been  properly  ad- 
justed to  surrounding  conditions,  it  should  be  gradually  accustomed  to  a 
temperature  cooler  than  the  ordinary  house  temperature.  The  windows  of 
the  room,  little  by  little,  should  be  opened,  and  the  fresh  air  treatment  which 
is  to  continue  throughout  childhood,  and  I  might  say  throughout  life, 
should  be  begun.  Depending  upon  the  season  of  the  year,  it  is  to  be  taken 
out  of  doors  for  a  short  or  a  long  time  each  day,  and  windows  are  to  be 
opened  so  that  it  shall  have  fresh  and  moderately  cool  air.  As  the  infant 
becomes  a  child  it  should  then  live  in  pure,  fresh  air  for  the  whole  twenty- 
four  hours.  Open-air  sleeping  apartments  and  wide-open  bedroom  win- 
dows make  this  possible  until  school  life  begins,  and  then  it  is,  as  a  rule, 
necessary  that  the  child  should  be  confined  for  a  few  hours  during  the  day 
to  the  schoolroom,  where  the  air  is  much  less  pure  than  out  of  doors  and 
in  homes  and  sleeping  apartments.  The  transition  from  the  coddling  and 
warmth  which  are  necessary  during  the  first  days  of  life  to  life  in  the  open 
air  throughout  the  twenty-four  hours  must  be  gradual.  It  is  only  when 
the  child  has  reached  the  age  of  three  years  that  it  can  be  readily  cared 
for  in  out-door  sleeping  apartments  during  the  winter  weather  in  our 
middle  and  northern  states. 


CARE  OF  INFANTS  AND  CHILDREN  5 

The  Nursery. — Where  it  is  possible,  a  large,  bright,  well-ventilated  room 
should  be  selected  for  the  nursery,  as  this  is  to  be  the  indoor  home  of  the 
child  during  the  early  years  of  its  life.  This  room  is  to  be  devoted  to  the 
infant  and  its  necessary  attendant,  and  is  not  to  be  a  reception  room  into 
which  all  interested  relatives  and  visitors  are  ushered  that  they  may  ob- 
serve a  wonderfully  precocious  and  beautiful  baby.  The  young  infant's 
undeveloped  and  .excitable  nervous  system  should  be  allowed  to  develop 
along  normal  lines  and  not  be  kept  in  a  constant  state  of  excitement  and 
stimulation  during  waking  hours.  The  nursery  should  be  free  from  heavy 
rugs  and  hangings,  as  simply  furnished  as  possible,  and  the  air  in  it  fresh, 
pure  and  free  from  contagion.  As  the  natural  instinct  of  the  infant  is  to 
j)ut  everything  into  its  mouth,  its  toys  and  other  things  w'ith  w'hich  it 
plays  should  be  of  such  a  character  that  they  may  be  easily  kept  clean  and 
the  infant's  surroundings  should  be  such  that  these  playthings  will  not  be 
contaminated  when  they  are  dropped  by  its  side.  Rubber  pacifiers  should 
not  be  tolerated ;  their  use  results  in  an  unhygienic  habit  which  it  is  difficult 
to  break.  During  the  early  months  of  life  the  infant  should  spend  nearly 
all  of  its  time  on  a  flat  mattress.  It  should  not  be  encouraged  to  sit  up  or 
to  stand  upon  its  feet  until  its  muscular  and  bony  development  are  such 
that  these  procedures  will  not  result  in  deformities  such  as  curvature  of  the 
spine  and  bow-legs. 

Clothing. — The  young  infant  must  be  rather  warmly  clad,  because  its 
heat-regulating  apparatus  is  not  sufficiently  developed  to  maintain  a  normal 
temperature  under  varying  degrees  of  heat  and  cold.  The  laity,  however, 
are  thoroughly  impressed  with  the  fact  that  the  newly-born  infant  requires 
more  than  the  ordinary  amount  of  clothing  to  keep  it  warm,  and  the  ten- 
dency therefore  is  not  only  to  clothe  the  infant  too  warmly,  but  to  bundle 
it  in  such  a  manner  as  to  interfere  with  the  free  expansion  of  its  lungs  and 
with  the  exercising  of  its  arms  and  legs.  Rarely  indeed  is  it  necessary  for 
the  physician  to  prescribe  more  clothing  for  the  newly-born  infant,  but,  on 
the  other  hand,  he  has  very  frequently  to  advise  the  mother  to  clothe  the 
infant  less  warmly  and  less  tightly,  especially  during  the  hot  summer 
months.  As  a  general  principle,  the  young  infant  requires  warmer  cloth- 
ing than  the  older  child,  yet  the  amount  of  clothing  required  must  vary 
with  the  season.  During  the  winter  and  cooler  months  of  the  year  the 
ordinary  flannel  abdominal  binder  may  be  used  for  two  or  three  months, 
and  is  then  to  be  changed  for  a  knitted  band  which  is  held  over  the  shoulders 
by  straps  and  pinned  below  to  the  diaper.  Long  stockings  reaching  to  the 
diaper  and  a  short  petticoat  and  dress,  suitable  in  weight  and  warmth, 
should  be  worn.  Even  in  early  infancy  it  is  not  advisable  to  have  long 
petticoats  and  dresses,  which  have  to  be  folded  about  the  feet  and  which 
interfere  with  the  freedom  of  action  of  the  legs.  The  feet  protected  by 
stockings  do  not  require  long  swaddling  clothes.  During  the  hot  months 
of  summer,  infants,  especially  those  in  our  large  cities,  should  be  very 
lightly  clad ;  on  very  hot  days  everything  may  be  removed  except  the  light 
knitted  band  and  diaper. 


6      GENERAL  HYGIENE   OF  INFANCY  AND   CHILDHOOD 

Contaeion-The  careful  avoidance  of  contagion  is  one  of  th^;»««t  im- 
tontagrion.      n  c  l  -  infnTirv     The  carelessness  with  which 

portant  principles  in  the  hygiene  of  intancy.     me  ta 
nf-int.  under  tlirce  montlis  of  age,  even  among  the  well-to-do  classes,  are 

V  o  Id  0  influenza,  bronchitis,  and  other  catarrhal  diseases  of  the  respira- 
expo^td  10  innutu    ,  sometimes  difficult  to  convince  even  mtelli- 

:::tS:^::r  i^wor^w^^^^^^  carefuny  isolate  the  young  infant 
frl  a  p  ailing  house  epidemic  of  la  grippe.  It  is  a  well-known  fact 
that  durLg  the  early  months  of  life  attacks  of  coryza,  influenza  bronchitis 

„d  other  contagions,  which  are  little  feared  by  the  older  members  of  the 
family,  may  readily  develop  into  serious  and  even  fatal  pneumonia  .  A 
governing  principle  in  every  household  should  be  that  a  sick  child  should 
be  carefully  quarantined  from  the  other  children  m  the  fami^,  nntil  the 
character  of  its  illness  is  definitely  determined,  and  if  this  illness  prov  s 
to  be  one  of  the  acute  infectious  diseases  the  quarantine,  so  opportunely 
begun,  should  be  rigidly  carried  out.  Whooping  cough  influenza  bron- 
chitis and  pneumonia  are  dangerous  diseases  in  early  infancy,  and  all  of 
the  ordinary  infectious  diseases  of  childhood  are  likely  to  run  a  much 
more  severe  course  in  the  young  infant  than  they  are  m  the  child.  The 
importance,  therefore,  of  having  a  nursery  which  may  serve  as  an  isolation 
room  for  the  well  infant  in  the  event  of  contagion  in  the  family  is  of  great 

importance.  ,  ,      , 

Excessive  Nerve  Activity.— As  the  child  reaches  school  age  excessive 
nerve  activity  (the  term  including  brain  work  and  nerve  excitement)  con- 
tinues to  be  a  very  potent  factor  in  the  production  of  disease.  The  hygiene 
of  childhood,  and  especially  that  pertaining  to  school  life,  should  therefore 
protect  the  growing  nervous  system  of  the  child,  that  it  may  be  relieved 
from  all  unnecessary  strain.^ 

Functional  nervous  diseases  are  greatly  increased  by  subjecting  the 
immature  nervous  systems  of  young  children  to  the  almost  constant  ex- 
citement, nervous  strain,  and  mental  activity  to  which  our  social  order 
subjects  them.  To  counteract  these  dangers  the  teachers  and  guardians 
of  the  young  must  be  taught  that  the  nervous  system  of  the  child  differs 
very  materially  from  the  nervous  system  of  the  adult;  they  must  be  con- 
vinced that  the  child,  especially  in  his  nervous  organization,  is  not  a  little 
man;  that  his  nervous  system  is  structurally  and  functionally  immature; 
that  it  is  excitable,  unstable  and  under  feeble  inhibitory  control ;  that  the 
sources  of  reflex  irritation  in  the  child  are  many;  that  the  nerve  centers 
discharge  their  force  more  fitfully  and  more  readily  than  in  the  adult; 
that  the  period  corresponding  with  the  onset  and  establishment  of  the  re- 
productive function  in  girls  is  a  time  when  they  are  especially  predisposed 
to  nervous  disease ;  that  the  brain  of  the  child  is  far  more  receptive,  imagi- 
native, emotional,  and  imitative  than  that  of  the  adult.  They  should  be 
*  The  following  paragraphs  in  this  chapter  are  modified  from  a  series  of  papers 
published  by  the  author  in  the  Archives  of  Pediatrics  in  1893-94,  under  the  title 
' '  Some  Physiological  Factors  of  the  Neuroses  of  Childhood, ' '  and  were  subsequently 
embodied  in  his  monograph  on  "The  Neurotic  Disorders  of  Childhood,"  E.  B.  Treat 
&  Co.,  1905. 


CARE   OF  INFANTS  AND   CHILDREN  7 

made  aware  that  these  and  other  physiological  peculiarities  of  the  nervous 
system  of  childhood  are  made  much  more  potent  for  evil  when  they  are 
associated  with  anemia,  malnutrition,  and  chronic  diseases,  Avhich -interfere 
with  the  physical  development  of  the  child. 

In  1892  W.  T.  Port<?r,  from  an  examination  of  33,500  hoys  and  girls 
in  the  St.  Louis  public  schools,  made  a  most  careful  study  of  the  "physical 
basis  of  precocity  and  dullness."  He  demonstrated  that  children  who  are 
advanced  in  their  studies  are,  on  the  average,  heavier,  taller  and  of  larger 
girth  of  chest  than  less  advanced  children  of  the  same  age.  If  the  ability  to 
succeed  in  school  is  a  measure  of  mental  power,  and  if  successful  scholars 
are,  as  a  rule,  better  developed  physically  than  the  less  successful,  it  follows 
that  mental  ability  is,  on  the  average,  greater  in  large  children  than  in 
small  children  of  the  same  age;  in  other  words,  there  is  in  the  child  a 
physical  basis  for  precocity. 

Porter  makes  a  practical  deduction  from  the  law  thus  established.  The 
entrance  to  any  grade  in  a  school  is  guarded  by  examination,  and  the  chil- 
dren found  in  that  grade  are  such  as  have  passed  the  entrance  examination 
and  have  in  this  way  shown  their  capacity  to  do  the  mental  labor  exacted 
of  them.  The  greater  number  of  these  children  are  of  the  same  age.  The 
work  of  this  grade  is,  then,  normal  for  this  age,  and  the  average  height, 
weight,  and  girth  of  chest  of  this  age  form  the  physical  development  most 
often  found  in  children  able  to  do  the  work  of  the  grade.  No  child  younger 
than  the  average  age  of  any  grade  should  be  permitted  to  enter  it  until  a 
physical  examination  has  shown  that  his  strength  will  probably  be  equal 
to  the  work,  or,  as  Porter  puts  it,  "No  child  whose  weight  is  below  the 
average  of  its  age  should  be  permitted  to  enter  a  school  grade  beyond  the 
average  of  its  age,  except  after  such  a  physical  examination  as  shall  make 
it  probable  that  the  child's  strength  shall  be  equal  to  the  strain."  In  de- 
termining this,  the  relation  of  weight  and  girth  of  chest  to  height  is  of 
special  importance.  Abnormal  height  is  undoubtedly  a  disadvantage,  yet 
such  children  may  be  able  to  do  their  school  work,  provided  their  physical 
development  is  in  proportion  to  their  height.  If  the  contrary  is  the  case,  the 
child  will  be  much  less  able  to  resist  the  strain  of  school  life,  and  should 
therefore  have  careful  physical  supervision  and  be  relieved  of  school  work 
when  he  commences  to  break  down  under  the  confinement  and  mental 
strain  incident  to  school  life. 

In  protecting  children  against  the  ill  effects  of  excessive  brain  work 
and  nerve  excitement.  Porter  calls  attention  to  the  importance  of  the 
frequent  weighing  of  growing  children,  and  says  that  the  failure  of  a  child 
to  make  the  normal  gain  in  weight  is  no  less  important  a  symptom  of 
physical  deterioration  than  persistent  lo^8_of  weight  in  the  adult.  Failure 
to  gain  in  weight  over  a  period  of  months  should  lead,  therefore,  to  an 
inquiry  into  the  child's  physical  condition,  into  his  school  tasks,  into  the 
number  of  hours  he  is  confined,  and  into  the  general  hygiene  of  his  home 
and  school  life.  If  this  rule  is  followed  many  children  will  be  saved  from 
serious  nervous  breakdowns. 


8      GENERAL  IIYGIEXE   OF  INFANCY  AND   CHILDHOOD 

It  is  my  belief  tliat  if  the  various  grades  in  our  public  schools  were 
guarded  by  a  physical  as  well  as  a  mental  examination,  along  the  lines 
above  indicated,  and  if  persistent  loss  of  weight  or  failure  to  gam  m  weight 
over  a  number  of  months  were  recognized  as  reasons  for  a  physical  inquiry 
into  the  child's  capacity  to  continue  in  its  grade,  the  functional  nervous 
diseases  of  childhood  would  be  much  less  prevalent  than  they  are  at  the 
present  time.  With  children  of  good  physical  development  working  within 
the  limitations  of  their  proper  grades,  there  is  no  danger  that  a  moderate 
amount  of  school  work  will  in  any  way  assist  in  the  development  of  neu- 
rotic disease,  provided  always  that  the  hygienic  conditions  of  the  school, 
especially  as  to  light  and  ventilation,  are  good,  and  provided  also  that  the 
rules  of  hygiene  pertaining  to  the  home  life  of  the  child  are  carried  out  as 
previously  outlined.  It  is  especially  important  that  children  who  spend  a 
great  portion  of  the  day  in  the  schoolroom  should  sleep  out  of  doors,  or 
with  wide  open  windows  at  night. 

The  nervous  strain  and  confinement  of  school  life  is  a  very  different 
matter  with  children  of  poor  physical  development,  many  of  whom  are 
unfortunately  precocious.  The  precocity,  however,  of  this  type  of  child  is 
fitful  and  is  not  sustained  throughout  the  school  year.  In  every  school  there 
is  a  large  number  of  children  who  are  neurotic,  poorly  nourished,  anemic, 
and  very  materially  underdeveloped,  and  not  a  few  of  these  are  suffering 
from  a  low  grade  of  glandular  tuberculosis.  The  nervous  systems  of  such 
children  are  malnourished,  and  they  are  therefore  not  capable  of  doing  the 
ordinary  work  of  their  grades,  and  if  they  are  permitted  to  continue  in  this 
work,  or  if,  as  is  often  the  case,  these  children  are  encouraged  to  push  on 
into  higher  grades  than  the  one  to  which  their  years  and  strength  would 
assign  them,  disastrous  consequences  will  surely  follow,  and  thej'^  will  be- 
come the  victims  of  chorea,  hysteria  and  other  neuroses.  If  the  medical 
supervision  of  our  schools,  which  at  the  present  time  is  concentrated  upon 
the  prevention  of  the  spread  of  contagious  diseases,  could  be  extended  so 
that  the  physically  weak  and  malnourished  child  could  be  referred  to  the 
family  physician  or  other  competent  medical  authority,  in  order  that  the 
question  of  the  advisability  of  its  continuing  to  do  its  full  school  work 
might  be  determined  before  a  physical  or  nervous  breakdown  necessitated 
the  withdrawal  of  the  child  from  the  school,  then  school  life  would  be  a 
much  less  important  factor  in  the  production  of  disease.  In  dealing  with 
children  of  poor  physical  development  it  is  not  always  advisable  to  remove 
them  entirely  from  school;  in  some  instances  it  may  be  wise  to  have  the 
child  go  to  school  only  during  the  morning  'session  and  to  arrange  its 
school  work  so  that  it  may  be  accomplished  without  nervous  strain.  In 
other  cases  the  child  may  be  temporarily  removed  from  the  school  and 
receive  home  instruction,  which  will  enable  it  to  keep  intellectual  pace 
with  the  children  of  its  school  grade.  In  every  such  instance  the  child 
must  be  kept  under  observation  until  its  physical  development  fits  it  for 
the  school  grade  to  which  its  age  and  intelligence  would  assign  it. 

It  is  my  belief  that  our  public  school  system  should  be  so  remodeled 


CAEE  OF  INFANTS  AND  CHILDREN  9 

that  all  children  under  twelve  or  fourteen  years  of  age  would  be  required 
to  spend  only  the  morning  or  the  afternoon  at  school.  The  present  system, 
which  requires  that  a  child  during  the  winter  months  should  spend  nearly 
all  the  daylight  hours  in  a  schoolroom,  is  bad.  It  is  a  fact  which  must  be 
evident  to  every  thinking  individual  that  if,  instead  of  spending  six  or  seven 
hours  of  the  day  in  a  schoolroom  filled  with  other  children,  where  the 
hygienic  conditions  are  bad  and  where  physical  exercise  is  largely  done 
away  with,  school  children  were  confined  for  three  or  four  hours  only  and 
were  permitted  to  devote  the  remainder  of  the  day  to  outdoor  play,  their 
physical  condition  would  be  greatly  improved  and  their  mental  development 
would  not  in  the  least  be  retarded. 

The  reasons,  then,  are  clear  why  we  should  not  allow  a  child  of  poor 
physical  development  to  be  pushed  to  rapid  brain  development.  If  we  do, 
its  nervous  system  will  surely  suffer  from  the  strain,  and  whatever  pre- 
disposition it  may  have  to  neurotic  or  other  chronic  diseases  will  be  greatly 
increased.  In  dealing  with  individual  cases  it  is  important  that  the  physi- 
cian should  know  the  child's  hereditary  tendencies.  He  cannot,  of  course, 
change  the  child's  ancestry,  but  he  can  speak  out  against  the  crime  of 
pushing  children  with  hereditary  physical  defects  to  rapid  brain  develop- 
ment, and  in  doing  so  he  may  prevent  the  development  of  an  hereditary 
constitutional  weakness  into  an  actual  disease. 

In  this  demonstration  of  the  injury  which  results  to  the  nervous  system 
of  the  delicate  child,  from  the  nervous  strain  and  unhygienic  conditions 
of  school  life,  we  have  a  most  important  warning  against  the  pernicious 
habit  of  encouraging  mental  precocity  in  early  childhood.  It  is  a  matter 
of  almost  daily  experience  to  see  a  poorly  nourished  and  perhaps  tuberculous 
child  brought  forward  for  the  purpose  of  demonstrating  its  '"wonderful" 
precocity.  The  proud  mother  and  overzealous  nurse  commence  the  process 
of  mental  cramming  even  before  infancy  has  passed  into  childhood.  From 
this  time  on,  children  are  daily  being  taught,  apparently  with  the  idea  of 
destroying  their  childhood  and  making  of  them  little  men  and  women. 
Mothers  must  be  told  that  early  precocity  is  an  abnormal  condition  in  the 
human  infant,  which,  if  encouraged,  may  result  in  actual  disease  and  per- 
manent mental  impairment.  They  must  learn  that  vegetation  is  the  ideal 
life  of  infancy  and  early  childhood,  and  that  in  order  to  get  the  best  results 
they  must  look  to  the  physical,  and  retard  the  intellectual,  development  of 
the  young  child.  It  must  not  be  taught;  it  must  not  be  trained;  it  must 
have  plenty  of  exercise,  fresh  air,  proper  food,  and,  if  possible,  should  spend 
a  portion  of  the  year  in  the  country  away  from  the  clamor  and  excitement 
of  city  life.  In  the  country  the  older  child  has  more  solitude,  and  must 
depend  more  upon  his  own  initiative,  the  importance  of  which  can  scarcely 
be  overestimated  in  giving  independence  of  thought  and  character  to  the 
future  man. 

In  the  modern  well-appointed  home  the  child  too  often  has  some  one 
to  do  his  thinking,  some  one  to  minister  to  his  every  want  and  some  one 
to  teach  or  amuse  him  throughout  his  waking  hours.     He  has  little  time 


10    GENERAL  HYGIENE   OF  INFANCY  AND   CHILDHOOD 

to  himself  and  a  very  small  portion  of  his  day  is  spent  in  play  with  his 
intellectual  equals.  Where  these  conditions  exist  there  is  little  chance  that 
the  best  possibilities  in  the  boy  will  be  utilized  for  making  the  best  possible 
man.  In  1893  I  wrote  as  follows:  "If  there  is  one  crying  evil  common  to 
all  of  our  large  cities,  it  is  the  scarcity  of  playgrounds  for  cliildren,  and  the 
attention  of  humanitarians  should  be  called  to  this  fact.  If  our  generous 
citizens  would  pause  long  enough  in  the  building  of  hospitals,  libraries  and 
places  of  learning  to  realize  there  is  a  field  almost  totally  neglected  by 
the  humanitarian  and  one  of  quite  as  much  importance  to  the  welfare  of 
our  communities,  then  possibly  a  portion  of  the  vast  sums  of  money  annually 
spent  in  this  way  would  be  used  in  providing  playgrounds  for  children. 
These  playgrounds  should  not  be  covered  with  beautiful  grass  plots  guarded 
by  policemen,  but  they  should  be  playgrounds  in  the  best  sense  of  the  word ; 
places  where  ball,  tennis  and  all  kinds  of  healthful  sport  could  be  enjoyed." 
Since  these  words  were  written  much  has  been  done  in  our  large  cities  to 
furnish  playgrounds  for  children,  and  a  movement  is  now  apparently 
spreading  over  the  country,  hand  in  hand  with  the  fresh  air  movement, 
which  is  teaching  the  poor  as  well  as  the  rich  that  healthful  play  in  the  open 
air  for  a  portion  of  the  day  and  healthful  sleep  in  fresh  flowing  air  at  night 
are  much  more  important  to  the  success  of  the  future  man  and  woman 
than  is  the  number  of  hours  spent  in  the  schoolroom.  The  day  has  appar- 
ently dawned  when  the  physiological  importance  of  the  physical  as  well  as 
the  mental  development  of  children  is  to  be  generally  recognized,  and  cities 
and  philanthropical  societies  will  be  called  upon  to  furnish  like  opportuni- 
ties for  the  development  of  both. 

In  the  hygienic  care  of  young  children  it  is  most  important  that  their 
irritable  and  undeveloped  nervous  systems  should  be  protected  as  much 
as  possible  from  reflex  excitation.  The  profound  nervous  disturbances 
which  may  be  produced  by  chronic  reflex  irritation  are  not  fully  recognized 
by  those  who  have  the  care  and  teaching  of  children.  Uncorrected  eye- 
strain, adherent  prepuce  and  clitoris,  chronic  adenoid  disease,  chronic  dis- 
ease about  the  rectum  and  intestinal  irritation  may  be  largely  responsible 
for  many  of  the  most  annoying  neurotic  disorders  of  childhood,  such  as 
headache,  night  terrors,  incontinence  of  urine,  hysteria,  chorea,  and  general 
nervous  excitability,  any  one  of  which  may  so  interfere  with  the  health  and 
comfort  of  the  child  as  to  make  it  impossible  for  him  to  continue  in  his 
school  work. 

The  fact  that  reflex  irritation  is  commonly  associated  with  other  factors 
in  the  production  of  disease  does  not  in  the  least  diminish  its  importance 
as  a  cause  of  neurotic  disease.  The  removal  of  the  reflex  excitant  in  many 
instances  cures  the  neurosis,  even  though  other  important  factors  remain, 
and  not  infrequently  our  best  efforts  at  removal  of  other  factors  of  neurotic 
disease  fail  to  produce  a  cure  as  long  as  the  reflex  excitant  remains  to 
constantly  irritate  the  nerve  centers.  The  explanation  of  these  clinical 
facts  is  that  reflex  irritation  does  not  act  simply  as  an  excitant  in  dis- 
charging nerve  force  from  irritable  centers,  but  it  also  acts  in  keeping  up 


CARE   OF   INFANTS  AND   CHILDREN  11 

the  irritability  in  these  centers,  and  if  long  continued  it  produces  changes 
in  the  nerve  centers,  recognizable  under  the  microscope.  C.  F.  Hodge  has 
shown  that  definite  clianges  occur  in  the  nerve  cells  of  the  brain  and  spinal 
ganglia  of  certain  birds  and  bees  as  a  result  of  their  normal  daily  activity. 
He  compared  the  nerve  cells  of  sparrows  and  swallows  shot  in  the  early 
morning  with  the  nerve  cells  of  sparrows  and  swallows  shot  in  the  evening 
after  a  day  of  hard  flight.  Experiments  of  this  kind  invariably  showed 
fatigue  changes  in  the  nerve  cells  tired  from  the  day's  work.  Hodge  also 
found  definite  changes  to  occur  in  the  spinal  ganglion  cells  of  the  frog, 
the  cat  and  the  dog  under  electrical  stimulation,  and  these  changes  were 
very  similar  to  the  changes  which  he  had  observed  to  result  from  the  normal 
daily  activity  of  nerve  cells.  He  also  observed  that  the  nerve  cell  recovered 
much  more  slowly  than  it  tired,  and  concludes  that:  "Individual  nerve 
cells  after  electrical  excitation  recover  if  allowed  to  rest  for  a  sufficient 
time,  but  the  process  of  recovery  is  slow.  From  five  hours'  stimulation 
recovery  is  scarcely  complete  after  twenty-four  hours'  rest."  In  these 
observations  we  have  an  explanation  of  the  disastrous  consequences  which 
result  to  the  immature  nervous  system  of  the  child  from  excessive  brain 
work,  nerve  excitement,  and  chronic  reflex  irritation,  and  we  have  also 
impressed  upon  us  the  important  physiological  fact  that  these  nerve  cen- 
ters, if  they  are  to  continue  to  do  their  best  work  and  functionate  in  a 
normal  manner,  must  have  long  periods  of  rest  to  recover  from  the  fatigue 
changes  which  normally  result  from  their  physiological  activity.  It  is  also 
a  fact  that  the  younger  the  child  the  more  pronounced  will  be  the  fatigue 
changes  resulting  from  physiological  or  pathological  activity  of  its  nerve 
cells,  and  therefore  the  longer  will  be  the  period  of  rest  required  to  restore 
these  nerve  centers  to  a  normal  condition. 

Reflex  irritation,  brain  work,  and  nerve  excitement  are  much  more 
potent  factors  in  producing  functional  nervous  diseases  in  the  child  than 
in  the  adult,  for  the  following  reasons : 

1.  The  nervous  system  of  the  child  is  more  irritable  and  unstable  by 
reason  of  its  incomplete  functional  development. 

2.  The  inhibitory  control  of  higher  nerve  centers  over  spinal  reflex 
movements  is  feebly  developed  in  the  child. 

3.  Blood  changes  associated  with  anemia  and  malnutrition  are  much 
more  common  allies  of  reflex  factors  in  producing  nervous  diseases  in  chil- 
dren than  they  are  in  adults. 

In  the  above  observations  we  have  not  only  a  physiological  but  also  a 
morphological  explanation  of  how  and  why  prolonged  brain  work,  nerve 
excitement  and  chronic  reflex  irritation  may  be  such  important  factors  in 
producing  all  kinds  of  neurotic  disorders  in  the  young  child.  It  follows, 
therefore,  that  in  the  hygienic  supervision  of  the  child,  if  these  diseases 
are  to  be  avoided,  not  only  all  the  general  hygienic  rules  which  have  been 
outlined  in  this  chapter  should  be  followed,  but  also  that  the  child  should 
be  carefully  examined  with  reference  to  reflex  causes  of  irritation  to  the 
nervous  system.     It  is  also  important  that  the  physician  should  recognize 


12      GENERAL  HYGIEXE  OF  IXFAXCY  AXD  CHILDHOOD 


Fig.  1. — Electrical  Sttmulation. — Cats. 
1.  Normal.     Left  spinal  ganglion  of  1st  thoracic  pair.     Osmic  acid. 
2.  Stimulated  5  hrs.     Mate  ganglion  to  1.     Osmic  acid. 
By  comparing  2  with  1  is  seen  the  effect  of  severe  work  (15  seconds'  stimulation  to 
45  seconds'  rest)  for  5  hours,  the  nuclei  becoming  darker,  shrunken  and  irregular 
in  outline,  protoplasm  somewhat  vacuolated.      (C.  F.  Hodge,  Journal  of  Mor- 
phology, Vol.  VII,) 


WEIGHT   DURIXG   INFANCY   AND   EARLY  CHILDHOOD  13 

the  fact  that  the  functional  development  of  the  male  and  female  genital 
organs  which  marks  the  approach  of  puberty  is  a  source  of  marked  reflex 
disturbance  which  may  greatly  predispose  to  neurotic  diseases,  and  that 
therefore,  during  this  period  of  Ufe,  children  should  be  more  carefully 
guarded  from  the  dangers  which  may  result  from  excessive  brain  work  and 
nerve  excitement.  Above  all,  the  importance  of  rest  to  the  nervous  system 
should  be  recognized  as  the  all-important  prophylactic  measure  in  prevent- 
ing disastrous  results  from  the  above  named  causes  of  disease,  and  that  this 
rest  can  only  be  satisfactorily  obtained  by  prolonged  periods  of  sleep.  Sleep 
is  ''nature's  sweet  restorer,'"  and  its  importance  as  a  preventive  of  disease  in 
childhood  cannot  be  overestimated.  It  is  a  most  important  part  of  the 
hygiene  of  infancy  and  childhood  that  children  from  the  beginning  of 
their  lives  should,  by  regulating  their  daily  routine  and  by  placing  them 
under  quiet  surroundings,  be  made  to  sleep  as  much  as  possible.  Even  after 
the  child  has  reached  the  school  age  it  should  be  sent  to  bed  very  soon 
after  its  evening  mfeal  so  that  if  possible  it  may  have  eleven  or  twelve  hours 
of  sleep.  If  the  habit  of  long  and  undisturbed  sleep  is  engrafted  firmly 
upon  the  infantile  nervous  system,  it  is,  as  a  rule,  easy  to  continue  it  into 
late  childhood,  and  if  parents  could  only  realize  the  enormous  benefit,  physi- 
cal and  mental,  which  its  continuance  would  bring  to  the  child,  then  they 
would  guard  and  protect  the  sleeping  habit  as  one  of  the  most  important 
heritages  of  infancy. 


CHAPTER  II 
GROWTH    AND    DEVELOPMENT 

Weight  during  Infancy  and  Early  Childhood. — The  increasing  weight 
of  the  infant  and  young  child  along  normal  lines  is  by  far  the  best  indica- 
tion of  satisfactory  growth  and  development.  There  are  many  signs  and 
symptoms  which  tell  of  the  unsatisfactory  development  of  the  child,  but 
these  for  the  most  part  derive  their  importance  from  their  association  with 
a  failure  to  gain  in  weight,  or  an  actual  loss  in  weight.  For  example,  an 
infant  that  is  making  the  normal  gain  in  weight  week  after  week  on  breast 
milk  may  have  curds  or  occasional  mucus  in  its  stools,  or  the  discharges 
from  the  bowel  may  vary  in  consistency,  may  at  times  be  green  in  color, 
and  the  infant  may  from  time  to  time  suffer  with  attacks  of  colic,  and  yet 
all  or  any  of  these  sj-mptoms  pointing  to  intestinal  indigestion  are,  as  com- 
pared with  a  normal  increase  in  weight,  of  comparatively  little  importance. 
In  such  cases,  of  course,  efforts  should  be  made  to  correct  the  indigestion  of 
the  infant  by  regulating  the  life  and  diet  of  the  mother  or  by  other  means 
outlined  in  the  chapter  on  Infant  Feeding;  but  the  fact  that  there  is  a 
steady  and  normal  gain  in  weight,  notwithstanding  the  other  symptoms 
that  may  be  present,  is  of  itself  sufficient  reason  for  continuing  the  child 
upon  the  mother's  milk.    On  the  other  hand,  the  stools  may  be  normal  and 


14  GROWTH   AND   DEVELOPMENT 

the  infant  may  be  comparatively  contented  with  its  food,  sleeping  and 
behaving  in  a  normal  way  in  all  other  particulars  except  that  it  is  failing 
to  gain  in  weight,  and  this  last  indication,  outweighing  all  of  the  others, 
indicates  that  the  food  of  the  infant  must  be  supplemented  or  changed. 

Failure  to  gain  in  weight  in  infancy  and  childhood  has  the  same  patho- 
logical significance  as  loss  of  weight  in  the  adult.  It  is  not  enough  that  the 
infant  or  young  child  should  hold  its  own  in  weight;  it  should,  if  its  nutri- 
tional problems  are  properly  solved,  increase  in  weight  in  the  ratio  that  is 
normal  for  its  age.  Slight  variations  in  weight  occur  from  unknown  causes 
in  the  young  infant;  the  weight  may  remain  stationary  for  three  or  four 
days  at  a  time  or  the  scales  may  record,  within  a  day  or  two,  a  gain  of  three 
or  four  ounces.  These  slight  variations  in  weight  from  day  to  day  should 
be  entirely  disregarded  except  perhaps  in  very  ill  or  in  very  young  or  pre- 
mature infants.  The  child,  under  ordinary  conditions  of  development, 
should  be  weighed  but  once  a  week  during  the  first  seven  months  of  life, 
and  thereafter  but  twice  a  month  during  the  first  year.'  During  the  second 
year  of  life  it  should  be  weighed  once  a  month,  and  during  the  third  and 
fourth  years  at  intervals  of  every  three  or  four  months.  By  these  regular 
weighings,  which  are  especially  important  during  the  first  year,  very  valu- 
able information  is  obtained  as  to  the  growth  and  development  of  the 
child.  Failure  to  gain  in  weight  fol*  one  or  even  two  weeks  may  not  always 
be  an  indication  that  the  infant  is  not  getting  proper  food  in  sufficient 
quantities,  since  not  infrequently  the  same  infant  after  such  a  standstill 
may  on  the  same  food  commence  to  gain  in  weight.  Too  much  importance, 
therefore,  must  not  be  placed  upon  the  temporary  failure  to  gain  in  weight 
of  an  infant  that  has  previously  been  developing  along  normal  lines.  If 
the  failure  to  increase  in  weight,  however,  continues  longer  than  three 
weeks,  and  especially  if  this  symptom  be  associated  with  others  indicating 
that  the  child  has  insufficient  or  improper  food,  then  prompt  steps  should 
be  taken  to  find  the  cause  of  the  trouble  and  to  relieve  it.  On  the  other 
hand,  it  is  well  to  remember  that  infants,  especially  those  fed  upon  the 
patent  foods,  may  increase  rapidly  in  weight  and  yet  not  be  properly 
nourished.  The  condensed  milk  and  patent  food  babies,  while  they  are  in- 
creasing rapidly  in  weight,  may  be  suffering  very  seriously  in  the  de- 
velopment of  their  osseous,  muscular  and  nervous  systems;  increase  in 
weight  on  ill-balanced  foods  may  go  hand  in  hand  with  the  development 
of  rickets.  While  it  is  true  that  the  increasing  weight  of  the  infant  is  the 
most  important  indication  of  its  satisfactory  growth  and  development,  it  is 
also  true  that,  if  one  depends  alone  upon  this  sign  of  normal  development, 
many  unfortunate  mistakes  will  be  made.  The  increase  in  weight  as  a 
sign  of  growth  and  development  is  to  be  studied  in  connection  with  other 
evidences  of  good  health  or  disease.  Weight  observations  are  made,  as  a 
rule,  by  the  mother  or  nurse,  and  too  often  are  they  taught  to  rely  exclu- 
sively upon  increase  in  weight  in  determining  the  physical  condition  of  the 
infant.  All  infants,  even  those  that  are  satisfactorily  gaining  in  weight, 
should  be  seen  and  carefully  examined  from  time  to  time  by  the  physician 


WEIGHT   DURING   INFANCY   AND  EARLY  CHILDHOOD    15 

in  order  to  determine  their  true  physical  condition.  The  infant  should  be 
stripped  and  weighed  upon  the  same  scales,  by  the  same  person  and  at  the 
same  time  of  day,  so  that  all  the  conditions  may  be  as  nearly  alike  as  pos- 
sible at  the  different  weighings. 

The  average  birth  weight  of  the  normal  infant  at  term  is  about  seven 
pounds;  female  infants  are,  on  the  average,  from  one-half  to  one  pound 
lighter  than  males.  Great  variations  in  the  birth  weight  may  occur;  in  full- 
term  infants  which  on  inspection  appear  to  be  satisfactorily  developed  a 
birth  weight  of  over  six  pounds  may  be  considered  normal.  In  proportion 
as  the  birth  weight  falls  below  six  pounds  the  vitality  of  the  infant  is  im- 
paired and  its  chances  for  normal  development  diminished.  The  infant 
loses  in  weight  for  two  or  three  days  following  its  birth ;  the  most  rapid  loss 
occurs  during  the  first  day,  and  by  the  third  or  fourth  day  the  child  begins 
to  slowly  gain  in  weight.  This  initial  loss  of  weight  amounts  to  from  five 
to  seven  ounces ;  the  lowest  weight  of  the  baby  is  commonly  found  on  the 
third  day,  and  by  the  end  of  the  first  week  it  regains  its  birth  weight.  This 
loss  of  weight  is  largely  due  to  the  discharge  of  meconium  and  urine  and  the 
absence  of  food  and  water.  If  newly-born  infants  are  given  water  to  drink 
(which  may  be  fed  to  them  with  a  medicine  dropper,  two  or  three  tea- 
spoonfuls  every  three  hours),  the  initial  loss  of  weight  here  described  will 
be  diminished,  and  the  water  thus  given  will  serve  a  valuable  purpose  in 
increasing  the  urinary  secretion  and  washing  out  the  tubules  of  the  kidney. 

From  the  end  of  the  first  week  the  normal  infant  gains  rapidly  in 
weight,  beginning  with  an  ounce  a  day,  or  about  two  pounds  every  month. 
This  rate  of  increase  is  maintained  up  to  and  perhaps  throughout  the  third 
month  of  life.  Toward  the  end  of  the  third  month  and  throughout  the 
fourth  there  is  a  slight  falling  off  in  this  gain  of  weight;  during  this  time 
the  increase  is  gradually  diminished  to  five  ounces  a  week,  and  the  infant 
still  continues  to  gain  slightly  less  in  weight,  until  at  the  end  of  the  sixth 
month  it  is  gaining  only  four  ounces  a  week.  From  this  time  to  the  end 
of  the  year  it  averages  from  three  to  three  and  one-half  ounces  a  week. 
By  this  rate  of  increase  an  infant  weighing  seven  pounds  at  birth  should 
weigh  fourteen  pounds  at  six  months  and  twenty  pounds  at  one  year  of  age. 
This  wonderful  growth,  by  which  the  infant  doubles  its  weight  during  the 
first  six  months  of  life,  and  almost  triples  its  weight  by  the  end  of  the 
first  year  of  life,  together  with  the  rapid  heat  loss  of  this  period,  is  responsi- 
ble for  many  of  the  physiological  and  pathological  peculiarities  of  infancy, 
and  explains  the  large  amount  of  food  required  per  kilogram  of  weight,  the 
intense  activity  of  the  metabolic  processes,  and  the  great  demands  made 
upon  the  excretory  organs  during  this  period  of  life. 

After  the  first  year  of  life  the  increase  in  weight  gradually  becomes  less 
rapid.  During  the  second  year  the  child  gains  about  three-fourths  of  a 
pound  a  month,  or  nine  pounds  during  the  year.  In  the  third  year  of  life  it 
gains  about  four  and  one-half  pounds ;  during  the  fourth  year  its  weight  is 
increased  three  pounds,  and  in  the  fifth  year  two  and  one-half  pounds,  at 
which  time  it  should  weigh  from  forty  to  forty-one  pounds.  From  the  end 
3 


16 


GROWTH    AND   DEVELOPMENT 


of  the  first  year  to  the  end  of  the  fifth  year  of  life  the  weight  of  boys  is 
from  one  to  one  and  one-half  pounds  heavier  than  girls,  and  this  superiority 
of  weight  in  boys  is  maintained  for  a  number  of  years  with  little  variation. 
The  acceleration  in  weight,  however,  which  precedes  puberty  takes  place 
earlier  in  girls  than  it  does  in  boys,  and  for  a  time  during  this  period  of 
their  lives  the  girls  are  the  heavier.  A  little  later  the  boys  regain  their 
superiority  in  weight  and  retain  it  until  maturity.  The  actual  and  com- 
parative rate  of  growth  of  33,500  boys  and  girls  in  the  public  schools  of 


AGE          7         8         9         10       II 

2        13        14        15        16         1 

116 

POU 

NDS 

112 

h 

124 

116 

108 

130 

112 

104 

''  1 

'A 

116 

108 

100 

// 

/ 

112 

104 

96 

/ 

108 

100 

92 

1 
/ 

1  / 
1  '  i 

/ 

104 

96 

5?  88 

/ 1 

1  / 

/  / 
/  / 

/ 

D 

100 

92 

0 
0  84 

/ 

/ 1 

1 1 

96 

88 

0 

^80 

/ 
/  > 

/ 1 

/  / 

/ 

92 
,88 

084 

2:6 

/ 

'/ 

/  / 

0 

5  80 

72 

.^ 

/ 

// 

/ 

=  84 

S76 

68 

/y 

1 

1 J 

f 

80 

72 

64 

/y 

/ 

/  / 

76 

68 

60 

y  • 

,' 

/ 

72 

64 

56 

y 

^^ 

A 

/ 

/ 

68 

60 

52 

y 

/y 

y. 

/y 

/ 

64 

56 

48 

yy 

/ 

// 

y. 

60 

52 

44 

. 

/y 

> 

/y 

56 

48 

/y 

yy 

52 

44 

y 

/.' 

r"" 

«8 

x^ 

y 
f 

44 

12        13 


14        15         16 


FiQ.  2. — The  Rate  of  Growth  in  Weight  of  Dull,  Mediocre  and  Precocious 

Boys  and  Girls. 

Full  lines  represent  boys'  weight.     Dashed  lines  represent  girls'  weight.     (W.  T.  Porter.) 

St.  Louis  is  graphically  shown  in  Figure  2,  taken  from  W.  T.  Porter.  He 
says :  "The  growth  of  boys  and  girls  runs  a  parallel  course  in  early  child- 
hood. At  age  six  boys  are  heavier  than  girls,  and  this  advantage  is  main- 
tained for  several  years.  But  when  the  difference  of  sex  begins  to  make 
itself  felt,  the  relation  between  the  weight  of  the  sexes  is  changed,  the  boys 
lose  their  superiority  and  the  curve  of  girls'  weight  rises  above  theirs.  This 
difference  persists  for  about  three  years,  and  then  the  curves  once  more 
cross  and  the  youth  is  once  more  heavier  than  the  maid.  In  the  plate  the 
curves  of  girls'  weight  cross  the  boys'  curves  at  the  same  age  in  dull, 
mediocre  and  precocious  children." 


HEIGHT    OF    CHILD    AT    DIFFERENT    AGES 


17 


Height  of  Child  at  Different  Ages. — The  average  length  of  the  male 
newly-born  infant  is  twenty  inches,  the  length  of  the  female  is  about  one- 
half  inch  less.  According  to  Eotch,  whose  figures  are  in  close  accord  with 
those  of  other  observers,  the  most  rapid  growth  occurs  within  the  first 
month,  during  which  time  the  infant  is  increased  in  length  one  and  three- 
fourths  inches  and  during  the  second  month  one  and  one-half  inches.  From 
the  third  to  the  twelfth  month  the  rapidity  of  growth  becomes  gradually 
less,  until  at  the  end  of  the  first  year  of  life  the  average  increase  is  about 
one-half  inch  per  month.  The  child  gains  eight  inches  in  length  during  the 
first  year;  three  and  one-half  inches  during  the  second  year,  and  three 
inches  during  the  third  year ;  thereafter  the  gain  is  from  two  to  two  and  one- 
half  inches  each  year  up  to  the  eleventh  year  of  life.  As  the  period  of 
puberty  approaches  there  is  a  more  rapid  gain  in  height,  which  corresponds 
rather  closely  with  the  rapid  increase  in  weight  which  occurs  at  this  period. 
This  increased  rate  of  growth  begins  about  the  twelfth  year  in  girls  and 
about  the  thirteenth  year  in  boys  and  continues  for  two  or  three  years,  and 
during  this  time  the  increase  in  height  is  from  three  to  four  inches  per 
annum.  It  is  not  improbable  that  the  rapid  body  growth  and  rapid  func- 
tional development  of  the  nervous  system,  which  are  frequently  associated 
with  nervous  irritability,  mental  precocity,  tachycardia,  headache,  and  other 
nervous  symptoms,  may  be  produced  by  excessive  activity  of  the  thyroid 
gland  which  occurs  with  the  approach  of  puberty.  At  any  rate,  it  is  im- 
portant to  recognize  the  fact  that  during  this  period  of  rapid  growth  and 
development  the  child  is  to  be  carefully  protected  from  excessive  brain  work 
and  nerve  excitement. 

The  following  tables  from  Koplik  give  the  average  height,  weight,  head 
circumference  and  chest  measurements  of  American  boys  and  girls.  They 
are  collated  from  thousands  of  children  in  various  states  by  Bowditch,  Burk, 
MacDonald,  Hastings  and  Chapin: 


Table  1 
From  Birth  to  Four  Years  of  Age 


Age 


Birth 

6  months 
12  months 

2  years.  . 

3  years. . 

4  years.  . 


Sex 


Boys 
Girls 
Bovs 
Girls 
Boys 
Girls 
Boys 
Girls 
Boys 
.  Girls 
Boys 
Girls 


Length 


In. 
19.7 
19.3 
25.4 
25.0 
29.5 
28.7 
33.8 
32.9 
37.0 
36.3 
39.3 
38.8 


Cm. 
50.0 
49.0 
64.8 
63.6 
73.8 
73.2 
84.5 
82.8 
92.6 
90.7 
98.2 
97.0 


Weight 


Lbs. 
7.4 
7.1 
16.0 
15.5 
21.5 
21.0 
30.3 
29.2 
34.9 
33.1 
37.9 
36.3 


Kilos. 
3.45 


7.2 

7.0 

9.8 

9.5 

13.8 

13.3 

15.9 

15.0 

17.2 

16.5 


Head 
Circum. 


In. 
13.8 
13.1 
16.0 
16.4 
17.8 
18.2 
19.3 
18.0 
19.3 
19.0 
19.7 
19.5 


Cm. 
35.1 
33.4 
40.5 
41.7 
45.3 
46.3 
49.0 
45.6 
49.0 
48.4 
50.3 
49.6 


Chest 
Girth 


In. 
12.6 
11.8 
15.7 
15.2 
17.8 
19.0 
20.0 
18.0 
20.1 
19.8 
20.7 
20.5 


Cm. 
32.0 
30.0 
39.9 
38.6 
45.1 
48.3 
50.8 
48.0 
51.1 
50.5 
52.8 
52.2 


18  GROWTH    AND   DEVELOPMENT 

Table  2 
From  Five  and  a  Half  to  Fifteen  and  a  Half  Years 


Years 
of  age 

Sex 

Height 

Weight 

Head 
Circum. 

Depth 
of  Chest 

Breadth 
of  Chest 

Chest 
Expansion 

In. 

Cm. 

Lbs. 

Kilos. 

1 
In. 

Cm. 

In. 

Cm. 

In. 

Cm. 

In. 

Cm. 

j  Boys 

41.7 

105.9 

41.6 

18.9 

20.1 

51.2 

4.9 

12.3 

7.1 

18.1 

1.3 

3.4 

oVi... 

\  Girls.... 

41.3 

104.9 

40.7 

18.5 

19.7 

50.2 

4.8 

12.3 

7.0 

17.7 

1.4 

3.5 

/  Boys 

43.9 

111.9 

45.2 

20.5 

20.2 

51.5 

5.0 

12.8 

7.2 

18.4 

1.6 

4.2 

6}^... 

Girls. . .  . 

43.3 

109.0 

43.4 

19.5 

19.  S 

50.3 

4.9 

12.3 

7.0 

17.7 

1.5 

3.8 

Boys .... 

46.0 

116.8 

49.5 

22.5 

20.4 

51.9 

5.1 

12.9 

7.4 

18.9 

1.8 

4.5 

7H--  • 

Girls 

45.7 

116.0 

47.7 

21.6 

20.0 

50.9 

4.9 

12.5 

7.2 

18.4 

1.8 

4.5 

8J4  . 

Boys. . . . 

48.8 

123.9 

54.5 

24.4 

20.5 

52.2 

5.1 

12.8 

7.6 

19.4 

2.3 

5.9 

Girls 

47.7 

121.1 

52.5 

23.8 

20.2 

51.2 

4.9 

12.5 

7.4 

18.9 

2.0 

5.0 

9>^. 

Boys 

50.0 

127.0 

59.6 

27.0 

20.6 

52.4 

5.2 

13.2 

7.8 

19.7 

2.5 

6.5 

Girls 

49.7 

126.2 

57.4 

26.0 

20.4 

51.9 

5.1 

13.1. 

7.0 

19.3 

2.2 

5.6 

10>^  . 

Boys 

51.9 

131.8 

65.4 

29.5 

20.6 

52.6 

5.2 

13.2 

8.0 

20.2 

2.7 

7.0 

1  Girls 

51.7 

131.3 

62.9 

28.5 

20.5 

52.0 

5.1 

13.0 

7.8 

19.8 

2.4 

6.0 

ni4. 

/Boys.... 

53.6 

136.1 

70.7 

32.2 

20.8 

52.9 

5.4 

13.8 

8.2 

20.9 

2.9 

7.3 

1  Girls 

53.8 

136.6 

69.5 

31 . 5 

20.7 

52.5 

5.2 

13.1 

8.0 

20.3 

2.6 

6.6 

im  . 

Boys. . . . 

55.4 

140.7 

76.9 

34.9 

21.0 

53.3 

5.6 

14.1 

8.5 

21.5 

3.0 

7.8 

Girls...  . 

56.1 

142.5 

78.7 

35.7 

20.9 

53.0 

5.4 

13.8 

8.4 

21.0 

2.4 

6.2 

13M  . 

/  Boys 

57.5 

146.0 

84.7 

38.5 

21.1 

53.5 

5.6 

14.3 

8.7 

22.7 

3.2 

8.2 

1  Girls...  . 

58.5 

148.6 

88.7 

40.3 

21.0 

53 . 5 

5.5 

14.1 

8.7 

22.1 

2.6 

6.6 

UH. 

/  Boys 

60.0 

152.3 

95.2 

43.2 

21.3 

54.1 

5.9 

15.0 

8.9 

22.7 

3.3 

8.4 

j  Girls.... 

60.4 

153.4 

98.3 

44.6 

21.3 

54.1 

5.7 

14.5 

9.0 

22.9 

2.7 

6.8 

15H- 

/  Boys 

62.9 

159.7 

107.4 

48.8 

21.4 

54.5 

6.3 

16.0 

9.3 

23.6 

3.3 

8.4 

\  Girls 

61.6 

156.4 

106.7 

48.5 

21.5 

54.6 

6.0 

15.3 

9.5 

23.8 

2.6 

6.5 

Head  Measurements. — Slight  variations  from  the  head  measurements  in 
the  above  tables  recording  the  maximum  circumference  at  different  ages  of 
infancy  and  childhood  may  occur  without  special  pathological  import,  but 
marked  variations  usually  have  pathological  significance.  On  the  average 
the  mentally  defective  have  smaller  and  less  symmetrical  heads  than  normal 
children  of  like  age.  When  symptoms  indicating  imbecility  in  the  infant 
exist,  a  small  circumference  of  the  head  associated  with  lack  of  symmetry 
of  the  skull  would  be  confirmator}'  evidence.  An  unusually  large  circum- 
ference of  the  head  when  associated  Avith  other  signs  of  hydrocephalus  may 
also  point  to  lack  of  mental  development.  It  should  also  be  remembered 
that  a  comparatively  large  head  is  a  not  uncommon  symptom  of  rickets  and 
cretinism. 

The  anterior  fontanels,  even  in  the  normal  infant,  may  vary  in  size 
from  one-half  inch  in  both  its  diameters  to  a  lateral  measurement  of  two 
and  one-half  inches,  and  an  anteroposterior  measurement  of  three  inches. 
This  opening  may  not  materially  decrease  in  size  until  the  eighth  or  ninth 
month,  when  it  gradually  begins  to  grow  smaller.  At  the  end  of  the  year 
it  should  not  be  more  than  one  and  one-half  inches  in  diameter  and  should 
be  closed  by  the  eighteenth  or  twentieth  month.  A'ariations  as  to  the  time  of 
closure  of  this  fontanel  may  occur,  within  the  limits  of  good  health,  from 
the  end  of  the  first  to  the  end  of  the  second  year  of  life.  Its  failure  to  close 
by  the  end  of  the  second  year  of  life  is  commonly  an  indication  of  rickets, 
of  malnutrition,  or  of  some  more  serious  disease  such  as  hydrocephalus  or 
imbecility.  The  posterior  fontanel  commonly  closes  within  the  first  six 
weeks,  but  in  deciding  upon  the  pathological  import  of  open  fontanels,  after 
their  normal  period  of  closure,  other  symptoms  must  be  taken  into  con- 


DEVELOPMENT   OF    SPINE   AND   BONY   FRAMEWOKK     19 

sidcration.  In  niicroci-'phalic  skulls  the  fontanels  may  close  and  premature 
ossification  of  the  sutures  may  occur  early.  This  condition  is  associated 
with  a  small,  asymmetrical  head  and  lack  of  development  of  the  brain. 
Both  hydrocephalus  and  microcephalus  are  elsewhere  described.  The  soft- 
ness of  the  skull  bones  and  the  open  fontanels  of  the  young  infant  pre- 
dispose it  to  pressure  deformities.  At  this  age  permanent  deformities  or 
irregularities  in  the  shape  of  the  skull  may  be  produced  by  permitting  the 
infant  to  habitually  rest  its  head  in  one  position. 

Development  of  the  Spine  and  Bony  Framework.  — The  spine  of  the  in- 
fant at  birth,  as  Eotch  has  noted,  contains  so  much  cartilage  and  so  little 
bone,  and  is  so  feebly  supported  by  weak  and  undeveloped  ligaments  and 
muscles,  that  it  can  be  easily  bent,  twisted,  and  deformed.  Instead  of  the 
normal  curves  of  the  self-sustaining  spinal  column  of  late  childhood  and 
adult  life,  there  are  present  the  position  'curves  which  result  from  bending 
and  twisting  the  soft  flexible  spine  of  the  infant  under  the  influence  of 
weight  and  i)ressure.  The  young  infant  should  spend  nearly  all  of  its  time 
in  a  prone  position.  It  should,  however,  be  shifted  from  side  to  side,  or 
back  to  stomach,  so  that  habitually  lying  in  one  position  may  not  pre- 
dispose to  permanent  pressure  deformity  of  the  head  or  the  spine.  As  the 
infant  groMS  older,  the  spine  becomes  stronger  and  more  capable  of  assisting 
in  the  support  of  the  body  of  the  infant,  but  it  is  important  that  during  the 
latter  half  of  the  first  year  of  life'  the  infant  be  not  encouraged  to  sit  up  too 
frequently  or  too  long  at  a  time.  Throughoi;t  early  childhood  there  is  a 
gradual  development  in  the  bones  and  supporting  ligaments  and  muscles  of 
the  spine,  but  long  after  school  life  has  begun  the  spinal  column  still  re- 
mains so  flexible  that  permanent  deformities  may  result  from  wrong  posi- 
tions in  writing  or  other  work  over  low  school  desks,  which  cause  the  child 
to  sit  for  hours  each  day  with  a  bent  or  twisted  spine.  This  is  a  common 
cause  of  spinal  curvatures  in  school  children,  many  of  which  are  so  pro- 
nounced that  the  most  skilful  orthopedic  treatment  over  a  period  of  years 
fails  to  remove  the  deformity  entirely. 

The  whole  bony  framework  of  the  child  is  in  an  active  stage  of  growth 
and  functional  development,  but  from  a  pathological  standpoint  the  most 
important  processes  are  taking  place  in  the  epiphyses  of  the  long  bones,  and 
in  the  small  bones  which  enter  into  the  formation  of  the  ankle  and  wrist. 
This  rapid  jnetabolism  and  growth  of  new  bone  predispose  this  part  of  the 
bony  framework  to  tuberculous,  pyogenic  and  other  infections. 

Pryor  used  the  development  of  the  bony  framework  of  the  wrist  as  an 
anatomical  index  to  the  general  development  of  the  skeleton,  and  his  tables 
show  that  the  bony  development  is  more  advanced  in  girls  than  it  is  in 
boys  of  the  same  age.  Eotch  in  a  very  clever  and  far-reaching  research  has 
demonstrated  that  Rontgenographs  of  the  carpal  bones  and  epiphyses  of 
the  radius  and  ulna  may  be  used  to  indicate  the  actual  bony  and  muscular 
development  of  the  child.  In  this  way  may  be  determined  the  anatomic 
age,  which  does  not  always  correspond  to  the  chronologic  age  of  the  child. 
The  anatomic  age,  as  determined  by  the  degree  of  development  of  the 


20 


GROWTH    AND   DEVELOPMENT 


carpal  bones  and  epiphyses  of  the  radius  and  ulna,  determines  the  degree 
of  development  of  the  whole  bony  and  muscular  framework  of  the  child, 
and  is  a  fairly  accurate  index  of  its  capacity  for  mental  and  physical  work. 
Rotch  says,  "The  people  must  be  educated  up  to  the  plane  of  intelligently 
seeing  that,  because  an  individual  has  been  born  three  or  four  years,  this 
does  not  necessarily  mean  that  such  chronologic  age  should  be  rigidly 
adopted  for  entering  a  kindergarten;  that,  because  it  is  six  or  eight  years 

of  chronologic  age,  it  should 
necessarily  be  in  the  usual 
grade  in  school  corresponding 
to  that  age;  that,  because  it  is 
ten  or  twelve  chronologic  years 
of  age,  it  should  necessarily  be 
grouped  in  athletics  with  boys 
or  girls  of  that  chronologic 
age;  or,  because  it  is  fourteen, 
fifteen  or  sixteen  years  of  age, 
it  should  be  allowed  to  work 
beyond  what  its  anatomic  de- 
velopment shows  it  can  do 
without  physical  harm,  as,  for 
instance,  in  the  mills." 

Eotch  has  worked  out  a 
practical  system  of  grading 
children  for  school  and  other 
work  which  will  correct,  he  be- 
lieves, the  errors  which  result 
from  the  classification  of  chil- 
dren for  this  work  by  their 
chronologic  age,  or  by  their  ap- 
parent physical  development  as 
determined  by  weight  and 
height.  The  value,  however,  of 
the  weight  and  general  appear- 
ance of  the  child  as  a  simple 
and  practical  method  of  classi- 
fying him  for  his  school  work  has  been  already  referred  to  and  must  for  a 
time  at  least  remain  the  simplest  and  most  practical  method  of  classification. 
The  more  scientific  and  more  accurate  method  of  determining  the  anatomic 
age  of  the  child  by  Eontgenization  may,  as  Eotch  believes,  in  time  super- 
sede the  cruder  and  simpler  methods. 

Muscular  Development. — The  general  bony  framework  of  the  body  keeps 
pace  with  the  muscular  development  of  the  child  and  attains  sufficient 
stability  to  support  the  positions  of  the  body  which  the  child  instinctively 
assumes  in  the  physiological  activity  of  its  developing  muscles.  It  is  in- 
advisable, however,  and  may  be  positively  injurious  to  place  the  child  in 


Fig.  3a. — Bad  Position  While  Writing. 
(After  Hoffa  in  Pfaundler  and  Schlossmann.) 


MUSCULAR    DEVELOPMENT 


21 


sitting  or  standing  positions  before  its  muscular  development  is  such  that 
it  voluntarily  or  instinctively  attempts  to  assume  these  positions.  The  young 
infant  as  it  lies  upon  its  back  should  have  perfect  freedom  of  muscular 
movement,  and  as  its  muscular  development  grows  apace  it  instinctively 
attempts  to  change  its  position.  It  does  not  have  to  be  taught  to  turn  over 
in  bed,  to  lift  its  head  from  the  pillow,  to  attempt  to  crawl  or  to  make  an 
effort  at  sitting  up  or  climbing  upon  its  feet;  all  of  these  movements  are 
instinctive  in  the  normal  child, 
and  they  are  exercised  as  soon 
as  its  muscular  development  is 
equal  to  the  physical  effort 
which  these  movements  entail, 
and  as  soon  as  the  bony  frame- 
work of  the  body  is  able  to  as- 
sist, without  injury,  in  sup- 
porting the  infant  in  these  po- 
sitions. At  birth  the  muscular 
development  of  the  hands  and 
forearms  is  relatively  stronger 
than  the  rest  of  the  body.  Tlie 
young  infant  clings  to  objects 
that  are  placed  in  its  hand, 
and  in  the  latter  part  of  the 
third  or  beginning  of  the 
fourth  month  it  reaches  for 
and  takes  hold  of  objects  which 
are  placed  in  front  of  it.  At 
birth  the  infant  is  unable  to 
hold  its  head  in  an  upright 
position,  but  during  the  third 
or  fourth  month  the  muscles 
of  the  neck  have  sufficiently 
developed  for  the  child  to  lift 
its  head  from  the  pillow  and 
hold  it  in  an  upright  position 
for  a  short  time.  From  this 
time  on  the  infant  begins  to  assume  positions  in  which  the  whole  spinal 
column  is  held  in  a  mild  degree  of  temporary  rigidity.  By  the  eighth  or 
ninth  month  it  may  be  able  to  sit  alone  for  a  short  time,  and  about  this 
time  it  begins  to  crawl  and  attains  in  a  mild  degree  the  faculty  of  volun- 
tary locomotion.  About  the  ninth  or  tenth  month  its  first  attempts  at  pull- 
ing itself  upon  its  feet  are  made,  and  thereafter  it  soon  acquires  the  power 
to  stand  and  to  make  an  effort  at  walking,  when  it  is  supported  by  a  chair  or 
some  other  object.  When  eleven  or  twelve  months  of  age  it  may,  while 
clinging  to  some  object,  begin  to  walk,  but  is  not,  as  a  rule,  able  to  walk 
alone  until  it  is  fifteen  or  sixteen  months  of  age.    It  should  be  remembered. 


Fig.  3b. — Bad  Position  While  Writing. 
(After  Hoffa  in  Pfaundler  and  Schlossmann.) 


22  GEOWTH    AND    DEVELOPMENT 

however,  that  even  in  normal  infants  there  is  considerable  variation  as  to  the 
time  when  they  begin  to  make  various  movements.  Some  may  walk  alone 
when  ten  or  eleven  months  of  age,  and  others  without  apparent  evidence  of 
disease  may  not  attain  this  faculty  until  they  are  eighteen  months  of  age. 
The  late  development,  however,  of  the  physical  functions  here  outlined  is, 
especially  when  associated  with  other  symptoms,  important  evidence  of  dis- 
ease cr  lack  of  development  on  the  part  of  the  nervous  system.  Inability 
to  hold  the  head  upright  at  the  fifth  month,  failure  to  reach  for  and  grasp 
objects  in  the  fifth  or  sixth  month  of  life,  failure  to  maintain  a  sitting 
position  at  one  year  of  age,  no  inclination  to  assume  the  upright  position 
at  the  eighteenth  month  and  failure  to  walk  when  two  and  one-half  years 
of  age  are  indications  not  only  of  lack  of  muscular  and  bony  development 
but  of  nervous  development  as  well.  In  such  instances  a  careful  search 
should  be  made  for  other  signs  of  disease  or  lack  of  development  of  the 
nervous  system. 

Special  Senses. — The  infant  during  the  first  few  days  of  life  is  deaf 
and  this  condition  perhaps  continues  until  the  Eustachian  tubes  are  cleared 
of  mucus,  and  air  has  found  its  way  into  the  internal  ear.  During  the  first 
three  or  four  days  the  infant,  for  this  reason,  sleeps  soundly,  undisturbed  by 
surrounding  noises.  From  the  third  to  the  fifth  day  there  are  indications 
that  the  child  hears  and  thereafter  this  sense  gradually  becomes  more  acute 
until  by  the  end  of  the  first  month  of  life  the  child  is  disturbed  by  slight 
noises,  and  by  the  end  of  the  fifth  or  sixth  month  it  is  able  to  distinguish 
between  and  interpret  certain  noises  such  as  the  sound  of  individual  voices. 
After  this  time  infants  are  very  sensitive  to  and  easily  frightened  by  loud 
and  unaccustomed  noises. 

Soon  after  birth  the  eyes  are  sensitive  to  light  and  for  this  reason  during 
the  first  weeks  of  life  they  should  not  be  exposed  to  bright  lights.  At 
the  end  of  the  second  or  third  week  the  eyes  of  the  infant  will  follow 
a  bright  light  as  it  is  moved  in  front  of  its  face.  From  this  time  on  it 
notices  more  and  more  bright  moving  objects,  and  at  the  end  of  the  third 
month  it  not  only  sees  all  objects  within  its  range  of  vision,  but  it  may 
give  evidence  that  it  recognizes  its  nursing  bottle  or  some  other  object 
which  it  has  seen  before. 

The  sense  of  taste  is  perhaps  slightly  developed  at  birth,  as  an  infant 
a  few  days  old  takes  sweetened  food  more  readily  than  it  will  sour  or  bitter 
liquids.  This  inborn  preference  for  sweet  food  is  not  to  be  unduly  en- 
couraged, as  even  very  early  in  the  life  of  the  infant  it  may  lead,  in 
artificially  fed  infants,  to  the  giving  of  an  excess  of  sugar  simply  because 
the  infant  demands  it. 

The  function  of  speech  is  developed  earlier  in  girls  than  it  is  in  boys. 
At  the  twelfth  or  thirteenth  month  the  infant  may  say  mama  and  papa, 
toward  the  close  of  the  second  year  simple  short  sentences  may  be  used, 
and  thereafter  the  faculty  of  speech  is  more  rapidly  developed.  It  is  not  a 
very  unusual  thing  in  children  of  normal  intellectual  development  to  have 
the  speech  faculty  delayed  for  a  year  or  more  after  the  time  when  it  is 


XEliVOUS  SYSTEM  U 

usually  acquired  by  the  normal  child.  These  children  all  through  the 
latter  half  of  the  first  year  of  life  and  through  the  second  year  manifest 
the  same  signs  of  intelligence  as  the  normal  child;  they  understand  every- 
thing that  is  said  to  them  and  make  their  wants  known  by  signs  and  by 
articulate  sounds  which  by  long  use  have  become  intelligible  to  those  around 
them. 

Nervous  System. — The  dura  mater  in  the  infant  is  closely  adherent  to 
the  skull,  and  the  blood  vessels  of.  the  pia  mater  are  so  abundant  and  so 
fragile  that  hemorrhage  into  the  subarachnoid  space  may  result  from  causes 
which  produce  high  blood  pressure.  This  accounts  for  the  not  infrequent 
occurrence  of  cortical  hemorrhage  during  labor  and  also  explains  why 
paroxysms  of  whooping  cough  and  severe  convulsions  may  produce  this  ac- 
cident in  older  children.  The  serious  effect  on  the  mental  and  physical 
development  of  the  child  which  results  from  these  hemorrhages  is  not  so 
much  due  to  their  extent  as  it  is  to  the  fact  that  they  produce  a  permanent 
cortical  lesion  in  the  young  and  immature  brain  which  interferes  with  its 
structural  and  functional  development. 

Of  all  the  vital  organs  the  nervous  system  at  birth  is  both  structurally 
and  functionally  the  most  immature.  Throughout  infancy  and  childhood 
the  nervous  system  develops  very  rapidly  in  size  and  structure  and  much 
less  rapidly  in  function.  In  the  later  years  of  childhood  the  functional  de- 
velopment of  the  entire  nervous  system  is  much  more  rapid.  From  birth 
up  to  the  seventh  year  of  life  the  brain  develops  enormously  in  weight, 
in  structure,  and  much  less  rapidly  in  function.  At  this  time  it  has  at- 
tained 90  per  cent,  of  its  maximum  weight  (Bo3'd),  and  thereafter  it  slowly 
increases  until  it  has  attained  its  maximum  size  at  the  age  of  eighteen ;  but 
increase  of  function  does  not  keep  pace  with  increase  of  weight.  While 
the  brain  of  the  child  at  eight  is  almost  as  large  as  that  of  the  adult,  as 
Clouston  says,  "The  difference  between  what  the  brain  of  a  child  of  eight 
and  the  brain  of  a  man  of  twenty-five  can  do  and  can  resist  is  quite  in- 
describable. The  organ  at  these  two  periods  might  belong  to  two  different 
species  of  animals  so  far  as  its  essential  qualities  go."  The  important 
structural  changes  in  the  brain  of  the  child  pertain  to  the  development  of 
the  convolutions  and  their  arrangement  in  groups  which  preside  over  spe- 
cial functions,  but  it  should  be  remembered  that  even  in  the  normal  child 
irregularities  may  occur  in  the  order  of  development  of  both  structure  and 
function.  It  is  quite  within  the  limits  of  health  that  certain  functions  of 
the  nervous  system  may  be  rapidly  developed  and  that  others  may  be 
unusually  retarded.  While  this  is  true,  the  important  pathological  fact 
must  be  kept  in  mind,  that  many  factors  such  as  heredity,  nutritional  con- 
ditions and  environment  have  a  very  powerful  influence  on  both  the  struc- 
tural and  functional  development  of  the  nervous  system,  and  these  factors, 
if  unfavorable,  seriously  retard  the  growth  of  the  nervous  system  in  both 
structure  and  function  and  very  commonly  interfere  with  the  order  of 
development  of  important  functions. 

The  most  important  clinical  fact  to  be  derived  from  these  observations 


24  GROWTH    AND   DEVELOPMEXT 

is  that  the  nervous  system  of  the  infant  and  young  child,  by  reason  of  its 
rapid  growth  and  immaturity,  is  characterized  by  marked  nervous  irrita- 
bility and  extreme  excitability,  and  that  this  normal  irritability  and  ex- 
citability of  nerve  cells  and  nerve  centers  in  the  young  nervous  system  may 
be  greatly  exaggerated  by  malnutrition,  bad  heredity  and  unfavorable  en- 
vironment. The  above  facts  in  part  explain  the  peculiar  susceptibility  of 
the  child  to  functional  nervous  diseases  and  also  explain  the  powerful  in- 
fluence of  bad  heredity,  malnutrition  and  unfavorable  environment  in  de- 
veloping and  aggravating  these  disorders  at  this  period  of  life. 

Feeble  inhibition  is  one  of  the  most  important  peculiarities  of  the 
nervous  system  of  the  child.  The  inhibitory  mechanisms  which  control  the 
discharge  of  nerve  force  that  regulates  such  vital  processes  as  the  action 
of  the  heart  and  lungs  are  fairly  well  developed  at  birth,  while  those  that 
regulate  reflex  phenomena  are  very  immature,  and  are  slowly  developed 
throughout  infancy  and  early  childhood.  The  late  development  of  the  func- 
tion of  inhibition  is  a  fact  of  great  importance  from  a  clinical  standpoint, 
because  this  is  the  last  function  of  the  cell  to  be  developed,  and  is  therefore 
the  one  that  is  most  likely  to  be  still  further  retarded  in  development  by 
bad  heredity,  malnutrition  and  unfavorable  environment.  It  is  the  ab- 
normally feeble  inhibition  which  occurs  in  the  abnormal  child,  brought 
about  by  the  above-named  unfavorable  conditions,  that  is  such  a  powerful 
factor  in  the  production  of  neurotic  disease  in  infancy  and  childhood. 

One  can  readily  understand  how  feel)le  inhibition  even  in  the  normal 
child,  by  reason  of  an  insufficient  control  over  the  convulsive  centers  at  the 
base  of  the  brain  and  reflex  centers  in  the  spinal  cord,  may  predispose  to 
convulsive  and  other  neurotic  disorders  of  childhood,  and  one  can  also 
readily  see  how  bad  heredity,  malnutrition  and  unfavorable  environment,  by 
retarding  the  normal  development  of  the  inhibitory  function  of  the  nervous 
system,  may  be  all-important  factors  in  the  development  of  these  neuroses. 

Certain  of  the  reflex  centers  in  the  spinal  cord  which  preside  over 
special  functions,  such  as  urination  and  defecation,  are  so  functionally  im- 
mature at  birth  that  there  is  a  lack  of  tone  of  the  sphincter  muscles  over 
which  they  preside,  and  as  a  result  we  have  an  incontinence  of  feces  and  of 
urine.  These  reflex  centers  are  slowly  developed  until,  under  their  control, 
the  muscles  of  the  bladder  and  rectum  acquire  the  normal  muscular  tone 
which  fits  them  for  the  purposes  they  are  to  serve,  and  with  this  development 
the  centers  in  the  cord  assume  control  of  the  rectum  at  about  the  fifth 
month  and  complete  control  of  the  bladder  muscles  at  about  the  end  of  the 
second  year  of  life. 

It  is  a  fact  of  great  physiological  and  pathological  importance  that  in 
the  development  of  the  spinal  cord  the  fibers  of  the  pyramidal  tract  are 
the  latest  to  become  myelinated.  At  birth  they  have  almost  no  myelin 
sheaths  and  until  these  are  developed  it  is  believed  that  motor  impulses 
cannot  readily  be  carried  from  the  brain  to  the  spinal  cord  cells.    ^  "Day  by 

*  For  a  fuller  discussion  of  the  physiological  peculiarities  of  the  nervous  system 
during  infancy  and  childhood,  see  the  author's  monograph  "Neurotic  Disorders  of 


DEVELOPMENT   OF   HEAT-REGULATING   MECHANISM     25 

day  as  these  myelin  sheaths  are  developed  the  cerebral  and  spinal  motor 
cells  are  brought  into  closer  communication  so  that  at  about  the  third  or 
fourth  month  this  communication  may  be  said  to  be  fairly  well  established; 
prior  to  this  time  the  communications  are  imperfect."  These  physiological 
facts  may  be  offered  in  explanation  of  the  comparative  immunity  which 
young  infants  have  from  convulsive  disorders  during  the  first  few  months 
of  their  lives,  and  they  may  also  explain  the  development  of  spastic  palsies 
as  late  as  the  third  or  fourth  month  of  life  which  are  due  to  natal  and  pre- 
natal injuries  to  the  brain. 

Development  of  the  Heat-regulating  Mechanism. — The  rectal  tempera- 
ture of  the  normal  newly-born  infant  at  term  ranges  between  99.5°  and 
100.5°  F.,  and  this  temperature  is  maintained  with  little  variation  through- 
out the  first  nine  months  of  life.  During  the  second  year  of  life  the 
normal  temperature  varies  from  99°  to  100°  F.,  and  thereafter  through- 
out early  childhood  the  rectal  temperature  is  from  99.6°  to  100.5°  F. 
Throughout  infancy  and  early  childhood  variations  in  temperature  between 
98.5°  and  100°  F.  are  of  little  or  no  pathological  significance.  Under  the 
heading,  Management  of  Premature  Infants,  the  fact  is  noted  that  in 
congenitally  weak  infants  the  temperature  ranges  much  lower  than  the 
figures  here  given.  It  is  a  notable  fact  that  slight  causes  acting  upon  the 
unstable  heat-regulating  mechanism  of  the  infant  and  young  child  will 
produce  high  and  variable  temperatures,  while  the  same  causes  acting  upon 
the  mature  nerve  centers  of  the  adult  may  produce  no  variations  in  the 
temperature  curve. 

The  thermogenic  or  heat-producing  centers  are ,  located  at  the  base  of 
the  brain.  These  centers  have  the  function  of  discharging  force  which  will 
increase  tissue  metabolism  and  thereby  increase  the  body  heat.  Any  disease 
or  injury  which  destroys  the  efficiency  of  these  centers  would  cause  a  de- 
crease of  the  body  heat,  and  any  condition  which  increases  the  irritation  of 
or  unduly  excites  these  centers  would  increase  the  body  heat.  Before  birth 
the  thermogenic  centers  are  in  a  state  of  immature  functional  development. 
In  the  human  infant  born  prematurely  they  are  so  imperfect  that  artificial 
heat  is  necessary  to  keep  the  body  warm,  and  this  artificial  heat  must  con- 
tinue to  be  supplied  until  these  immature  centers  have  developed  to  such  a 
state  of  physiological  competency  that  they  are  able  to  supply  to  the  body 
the  normal  amount  of  heat.  In  the  normal  infant  at  birth,  although  these 
centers  have  a  fair  degree  of  physiological  competency,  they  are  still  im- 
mature, and  much  more  unstable  than  they  are  in  the  finished  brain  of 
the  adult.  The  comparative  instability  and  excitability  of  the  thermogenic 
centers  of  the  infant  and  young  child  cause  them  to  discharge  their  nerve 
force  and  increase  the  body  temperature  from  slight  causes,  and  in  this  fact 
we  find  one  of  the  explanations  of  the  proneness  of  infants  and  young  chil- 
dren to  develop  high  temperatures  from  slight  causes. 

Like  other  nerve  centers  in  the  unfinished  brain  of  the  child  the  thermo- 

Chiklhood,"  1905,  and  "Clinical  Significance  of  Lack  of  Development  of  the  Pyra- 
midal Tracts  in  Early  Infancy,"  Archives  of  Pediatrics,  1910. 


26  GROWTH    AND   DEVELOPMENT 

genie  heat  centers  have  their  uoriiial  irrital)ility  and  excitability  very  greatly 
exaggerated  by  neurotic  inheritance,  malnutrition  and  unfavorable  environ- 
ment. It  is  tlie  abnormal  excitability  of  these  centers  in  the  nervous,  mal- 
nourished, anemic  child  that  explains  the  special  predisposition  which  some 
children  have  to  fever  from  slight  causes. 

The  thermoinhibitory  centers  are  located  in  the  cerebral  cortex  and  it  is 
their  function  to  control  or  prevent  the  discharge  of  nerve  force  from  the 
thermogenic  centers.  Tlie  thermogenic  and  tliermoinhibitory  centers  have 
their  functions  so  nicely  balanced  in  the  normal  adult  nervous  mechanism 
that  with  the  aid  of  the  heat-dissipating  centers  they  are  able  to  maintain 
the  body  at  almost  a  uniform  temperature  under  the  most  adverse  circum- 
stances. But  in  the  infant  and  young  child  the  thermogenic  centers  are 
not  only  irritable  and  excitable,  but  they  are  under  comparatively  feeble 
inliibitory  control  from  the  thermoinhibitory  centers,  and  this  feeble  inhibi- 
tion of  the  thermogenic  centers,  which  predisposes  the  normal  child  to  high 
and  variable  temperatures  from  slight  causes,  is  much  more  feeble  and 
therefore  much  less  effective  in  children  of  bad  heredity,  malnutrition,  and 
unfavorable  environment.  It  is  therefore  the  abnormally  feeble  inhibition 
of  the  nervous,  malnourished,  anemic  child  which  leads  to  loss  of  control 
of  the  thermogenic  centers,  that  especially  predisposes  certain  children  to 
high  and  variable  temperatures.  McAllister  says,  "The  inhibitory  is  the 
first  portion  of  the  heat-regulating  mechanism  to  fail  under  injury  or 
disease." 

The  heat-dissipating  mechanism  plays  a  much  more  important  part  in 
regulating  the  temperature  of  the  body  in  the  infant  and  child  than  it  does 
in  the  adult.  This  is  the  mechanism  by  which  the  infant  keeps  itself  cool 
when  from  insufficiency  or  maladjustment  of  the  thermogenic  and  thermo- 
inhibitory centers  the  temperature  of  the  child  is  raised  above  the  normal 
point.  The  dissipation  of  heat  by  radiation  and  conduction  and  by  the 
constant  evaporation  of  water  from  the  surface  of  the  body  is  much  more 
rapid  in  the  infant,  because  the  area  of  skin  surface  is  from  four  to  six 
times  greater  in  the  infant  and  young  child  in  proportion  to  its  body 
weight  than  it  is  in  the  adult.  For  these  reasons  the  heat-dissipating 
mechanism  of  the  infant  is  four  times  as  effective  as  it  is  in  the  adult.  In 
the  above  physiological  facts  we  have  an  explanation  of  why  the  high 
temperatures  of  infancy  and  childhood  are  so  readily  reduced  by  the  heat- 
dissipating  mechanism,  and  we  also  have  an  explanation  of  the  compara- 
tively rapid  reduction  of  temperatures  at  this  time  of  life  from  hydro- 
therapeutic  measures  and  from  medical  antipyretics.  These  latter  act  not 
only  on  the  thermogenic  centers  in  diminishing  the  amount  of  heat  pro- 
duced, but  they  also  act  through  the  vasomotor  nervous  mechanism  and 
cause  a  profuse  perspiration  with  a  resulting  rapid  evaporation  of  the 
water  from  the  surface  of  the  body.  It  will  thus  be  seen  that  the  heat- 
dissipating  mechanism  in  infancy  and  childhood  is  much  more  effective  than 
it  is  in  later  life,  and  that  in  the  play  of  function  between  this  mechanism 
and  that  of  the  heat-generating  and  heat-inhibiting  mechanism  we  have  an 


EVAPORATION  OF  WATER  FROM  AIR  PASSAGES    27 

explanation,  not  only  for  the  high  temperatures  which  occur  during  infancy 
and  childhood  from  slight  causes,  but  also  for  the  unusual  variations  in  the 
temperature  which  occur  at  this  period  of  life.  As  the  infant  develops  into 
the  child  and  as  the  child  grows  older  there  is  a  gradual  functional  develop- 
ment of  the  heat-regulating  apparatus.  The  thermogenic  centers  become 
less  irritable  and  are  therefore  not  so  easily  excited  to  produce  fever  from 
slight  causes.  The  thermoinhibitory  centers  gradually  increase  their  effi- 
ciency aijd  exercise  more  and  more  control  over  the  tliermogenic  centers; 
this  is  especially  important  in  increasing  the  stability  of  these  heat  centers, 
and  of  preventing  fever  from  slight  causes.  With  this  increase  in  stability 
and  functional  capacity  of  the  heat  centers,  the  heat-dissipating  mechanism 
also  becomes  more  stable  and  does  not  respond  so  readily  to  hydro  therapeutic 
and  other  measures  commonly  used  for  the  reduction  of  temperature. 

Evaporation  of  Water  from  the  Air  Passages.^ — In  certain  animals,  the 
dog  for  instance,  whieli  do  not  sweat,  tlie  evaporation  of  water  from  the 
air  passages  is  the  chief  means  of  reducing  the  body  temperature.  Richet 
calls  the  rapid  respirations  of  the  panting  dog  polypnea;  by  these  rapid 
respirations,  amounting  to  as  many  as  four  hundred  in  a  minute,  the  heat 
of  the  body  is  rapidly  given  off.  Richet  proved  that  the  polypneic  center 
was  not  affected  by  the  amount  of  carbonic  acid  or  oxygen  in  the  blood, 
and  that  it  was  solely  for  the  purpose  of  heat  dissipation. 

Does  tlie  polypneic  center  exist  and  is  it  functionally  active  in  infancy 
and  childhood?  The  answer  to  this  question  has  important  clinical  bear- 
ings. Ott  says:  "In  infants  we  see  a  polypnea  during  fever,  the  respira- 
tion rises  in  frequency  with  the  rise  in  temperature."  Every  physician  must 
have  seen  many  cases  of  rapid  respiration  in  children  that  could  not  be 
accounted  for  by  pulmonary  disease.  It  not  infrequently  happens  that  a 
child  with  fever  will  have  sixt}^  eighty  and  one  hundred  respirations  per 
minute,  without  presenting  any  sign  or  symptom  of  lung  trouble.  Polyp- 
nea is.  to  my  mind,  the  explanation  of  this  phenomenon.  Very  rapid 
breathing  is  a  common  symptom  of  gastrointestinal  disorders,  and  in  many 
cases  means  nothing  more  than  nature's  attempts  at  heat  dissipation.  The 
importance  of  recognizing  polypnea  as  a  symptom  of  fever  in  infancy  and 
childhood  is  great.  If  we  do  not  do  this,  we  may  often  be  led,  by  the  rapid 
breathing,  away  from  the  real  cause  of  the  disease.  Fortunately  for  us  as 
clinicians,  there  is  a  marked  difference  between  the  character  of  the 
polypneic  breathing  and  the  rapid  respirations  due  to  lung  or  heart  dis- 
ease. In  polypnea  the  breathing  is  regular,  easy  and  rapid,  but  is  not, 
as  it  is  in  lung  and  heart  disease,  irregular,  labored  and  accompanied  by 
cyanosis. 

^"Neurotic  Disorders  of  Childhood,"  by  B.  K.  Rachford,  E.  B.  Treat  &  Co., 
N.  Y.,  1905. 


28  EXAMINATION    OF    THE    SICK    CHILD 

CHAPTER  III 
EXAMINATION    OF    THE    SICK    CHILD 

HISTORY  OF  THE  CASE 

Present  Illness. — The  first  step  in  the  routine  examination  of  the  sick 
child  is  to  listen  attentively  to  the  mother's  and  nurse's  story  of  the  child's 
present  illness.  In  this  short  narrative  the  physician  should  obtain  clues 
which  will  materially  assist  him  in  his  own  careful  physical  examination 
of  the  child.  It  is  all  very  well  for  us  to  say  that  a  full  and  complete  ex- 
amination should  be  made  of  every  sick  child,  but  this  is  manifestly  impos- 
sible and  in  a  sense  unnecessary.  It  would  be  unwise  and  unnecessary,  even 
if  the  physician  had  the  time,  to  thoroughly  examine  in  every  case  presented 
to  him  the  blood,  the  sputum,  the  stools,  the  cerebrospinal  fluid  and  the 
gastric  contents,  or  to  test  the  child's  special  senses  and  make  a  thorough 
examination  of  all  of  its  reflexes.  These  and  many  other  special  examina- 
tions may  be  suggested  by  the  story  of  the  child's  illness  or  by  the  subse- 
quent careful  physical  examination  to  which  the  child  is  subjected.  The 
diagnostic  skill  of  the  physician  will  largely  depend  on  his  ability  to  de- 
termine from  the  mother's  story  what  should  be  the  character  of  his  pre- 
liminary examination  and  to  judge  from  the  findings  of  this  examination, 
or  the  subsequent  developments  of  the  case,  what  special  examinations  may 
be  necessary  to  clear  the  diagnosis  in  an  individual  case. 

Previous  Medical  History. — Obtain  the  medical  history  of  the  child  as 
to  previous  illnesses  and  especially  as  to  similar  attacks;  the  character  of 
food  it  has  been  taking ;  the  regularity  of  its  habits  in  eating  and  sleeping ; 
gastrointestinal  disorders ;  acute  infectious  diseases ;  nervous  disturbances 
and  possible  birth  and  subsequent  injuries.  Special  inquiry  along  certain 
lines  suggested  by  the  story  of  the  present  illness  may  bring  forth  facts  of 
great  importance  in  the  child's  previous  history  which  the  mother  would 
otherwise  have  overlooked. 

Family  History. — With  the  story  of  the  child's  previous  and  present 
illness  in  mind,  the  physician  is  better  prepared  to  obtain  from  the  mother 
such  facts  in  the  family  history  as  may  have  a  bearing  upon  the  case.  It 
is  especially  important  to  know  the  number  of  other  living  children  and 
their  general  health ;  the  number  of  the  dead  and  the  causes  of  their  death. 
It  may  be  necessary  in  an  individual  case  to  inquire  carefully  into  the 
family  history  with  reference  to  syphilis,  tuberculosis,  nervous  disorders, 
gout,  autotoxic  attacks,  gastrointestinal  disturbances,  a  hemorrhagic  diathe- 
sis, or  other  conditions  in  the  ancestry  of  the  child,  which  may  throw  light 
upon  its  present  illness. 


PHYSICAL  EXAMINATION  29 


PHYSICAL  EXAMINATION 

If  the  child  is  approached  gentl}^  and  tactfully  it  is  possible  to  make  this 
examination  without  resistance  from  the  little  patient.  In  order  that  the 
various  steps  of  the  physical  examination  may  be  made  under  the  most 
favorable  conditions  it  is  wise  to  postpone  the  taking  of  temperature  and 
the  examination  of  the  throat  until  the  last,  as  these  procedures  may  irri- 
tate the  child. 

The  rectal  temperature  should  be  taken  at  the  first  examination  and 
thereafter  should  be  recorded  at  least  twice  a  day  until  a  diagnosis  is 
reached.  In  many  instances  it  is  necessary  to  take  the  temperature  at  three- 
hour  intervals,  and,  as  a  rule,  it  is  advisable  that  a  careful  temperature 
record  be  kept  until  the  child  is  convalescent.  The  value  and  significance 
of  temperature  observations  have  been  outlined  in  the  chapter  on  Fever. 

The  weight  of  the  child  should  be  ascertained,  if  possible,  at  the  first 
examination.  This  observation  helps  the  physician  in  determining  the 
child's  general  physical  condition  and  when  compared  with  future  weigh- 
ings enables  him  to  determine  whether  the  child  is  losing  or  gaining 
weight.  The  importance  of  failure  to  gain  in  weight,  as  an  indication  of 
disease  in  the  growing  child,  has  been  referred  to  in  the  chapter  on  Growth 
and  Development. 

Inspection. — More  information  may  be  obtained  by  inspection  than  by 
any  other  method  of  physical  examination.  That  this  may  be  thorough, 
the  whole  body  of  the  child  should  be  examined.  The  experienced  eye  can 
almost  at  a  glance  read  the  nutritional  history  of  the  child  in  the  general 
picture  which  its  nude  form  presents.  It  is  important  to  note  muscular 
development,  general  emaciation,  the  size  and  shape  of  the  head,  thorax  and 
abdomen,  skin  eruptions,  deformities,  localized  inflammations,  and  the 
presence  or  absence  of  the  external  signs  of  rickets,  hereditary  syphilis, 
gastrointestinal  diseases,  and  anemia. 

Face  and  Head. — The  facial  expression  may  tell  of  the  presence  of 
adenoids,  paralysis,  and  cretinism  and  other  forms  of  idiocy.  The  sunken 
eyes,  pinched  features  and  dull  stare  of  the  child  indicate  the  extreme 
gravity  of  the  illness.  The  small  wasted  face,  large  head  and  open 
fontanels  tell  the  story  of  long  illness  from  some  chronic  wasting  disease. 
The  rachitic  head,  the  microcephalic  head  and  the  hydrocephalic  head  are 
readily  recognized.  Opisthotonos,  stiffness  of  the  spine  and  a  position 
which  shields  the  eyes  from  light  suggest  meningeal  inflammation.  If  the 
head  falls  loosely  in  the  direction  gravity  directs,  and  the  spine  shows  by 
its  abnormal  flexibility  a  lack  of  muscular  development,  it  may  be  in- 
ferred there  is  also  a  lack  of  mental  development.  Inspection  of  the  throat 
and  mouth  commonly  throws  light  on  the  character  of  the  child's  illness. 
One  should  observe  the  character  of  the  tongue ;  local  diseases  of  the  tonsils, 
pharynx,  and  mucous  membranes ;  the  membrane  of  diphtheria ;  the  scarla- 
tinal sore  throat,  the  enanthems  of  measles  and  of  the  other  acute  exanthe- 


30  EXAMINATION    OF    THE    SICK    CHIED 

niata;  abiionnalitios  as  to  the  formation  of  the  todh  and  the  order  of 
their  eruption ;  hemorrhagic  and  other  diseased  conditions  of  the  gums,  and 
deformities  in  the  shape  and  general  contour  of  the  palate.  The  skin 
should  be  carefully  examined  and  one  should  note  the  presence  and  char- 
acter of  all  rashes;  desquamation  of  the  skin  and  its  character;  cyanosis 
and  its  possible  relation  to  dangerous  cardiac  and  respiratory  diseases; 
petechial  and  other  hemorrhagic  eruptions;  jaundice  as  shown  by  the  yel- 
lowish discoloration  of  the  skin  and  conjunctiva;  edemas,  both  general 
and  localized,  the  former  pointing  to  ne])hritis,  the  latter  to  urticaria  and 
gastrointestinal  disorders;  marked  pallor  of  the  conjunctiva  and  skin,  with 
or  without  edema,  which  may  give  a  clue  to  grave  blood  lesions;  syphilitic 
lesions  about  the  anus;  irritations,  catarrhal  inflammations  and  other  ab- 
normalities of  the  genitalia,  and  clubbing  and  blueness  of  the  finger  tips 
which  may  point  to  some  grave  lesion  of  the  circulatory  or  respiratory 
apparatus. 

The  GENERAL  POSITION  of  the  child  lying,  sitting  or  standing  gives 
much  information.  In  pleurisy  and  pneumonia  it  may  lie  upon  the  affected 
side,  holding  its  chest  wall  and  evincing  characteristic  pain  by  its  facial 
expression  and  by  crying  out  when  it  is  moved.  In  abdominal  pain  it 
usually  lies  upon  its  back  with  its  thighs  flexed  upon  its  abdomen;  this 
position  is  common  in  appendicitis,  peritonitis,  typhoid  fever  with  abdom- 
inal distention,  and  in  severe  attacks  of  intestinal  colic.  In  the  standing 
position  curvatures  of  the  spine,  bow-legs  and  other  body  deformities  are 
readily  detected. 

Eespiratory  movements  should  be  carefully  observed  while  the  child 
is  at  rest.  Marked  dyspnea,  with  retraction  of  the  chest,  and  dilatation  of 
the  alse  nasi  may  not  only  point  to  bronchopneumonia,  but  may  indicate 
the  seriousness  of  this  disease,  or  the  same  symptom  group  slightly  modified 
may  be  caused  by  an  obstructive  lesion  in  the  larynx,  such  as  may  occur 
in  diphtheria  and  catarrhal  laryngitis.  In  very  young  infants  difficult  and 
interrupted  breathing  may  result  from  nasal  obstruction  caused  by  syphilis, 
acute  rhinitis,  or  retropharyngeal  abscess.  Slow  and  irregular  respiratory 
movements  may  be  due  to  intracranial  disease. 

Palpation  or  Digital  Examination. — The  head  and  neck  are  fruitful 
fields  for  this  form  of  examination.  One  should  note  the  shape  of  the 
head,  size  of  the  fontanels,  thinness  of  the  cranial  bones,  hypertrophied 
tonsils,  enlargement  of  cervical  lymphatics,  and  swelling  of  the  parotid 
and  other  salivary  glands.  A  digital  exploration  may  reveal  adenoid  dis- 
ease or  other  abnormalities  in  the  pharynx. 

Palpation  of  the  chest  may  reveal  the  rickety  rosary,  or  other  bony 
deformities,  the  fremitus  produced  by  the  voice  and  by  bronchial  and 
sibilant  rales,  inequalities  in  the  movements  of  the  two  sides  of  the  chest, 
the  location  of  the  apex  beat  of  the  heart,  and  the  cardiac  thrill  when 
present.  By  palpation  one  also  determines  the  rate  and  character  of  the 
pulse  and  general  and  local  enlargement  of  superficial  lymphatic  glands. 

In  the  abdomen  one  may  discover  by  palpation  localized  or  general 


PHYSICAL    EXAMINATION  31 

tonicity  and  resistance  of  the  abdominal  wall,  so  important  in  the  diagnosis 
of  apj)endicitis,  peritonitis  and  other  abdominal  diseases;  fluid  in  the  ab- 
dominal cavity;  enlargement  of  the  spleen  and  liver;  displacement  and 
enlargement  of  the  kidneys;  tumors  and  other  abnormalities.  The  liver 
normally  extends  one  inch  below  the  margin  of  the  ribs  when  the  child  is 
lying  upon  its  back;  it  is  therefore  readily  palpable,  and  enlargements  are 
easily  detected.  The  spleen  when  easily  palpable  is  enlarged  and  is  a  diag- 
nostic sign  of  great  importance  in  typhoid  fever,  leukemia,  von  Jaksch's 
disease,  chronic  forms  of  tuberculosis  and  malaria.  Enlargement  of  the 
spleen  may  also  occur  in  the  acute  infections,  chronic  gastrointestinal  dis- 
eases and  chronic  forms  of  sepsis. 

In  the  upper  and  lower  extremities  one  may  discover  tenderness  and 
rigidity  of  the  joints,  deformities  and  lack  of  symmetry  in  development. 

The  method  of  examination  for  determining  the  rigidity  of  the  spinal 
COLUMN  is  important.  Curvatures  of  the  spine  are  readily  discovered  when 
the  cliild  is  undressed,  but  the  character  of  these  curvatures  can  only  be 
made  out  by  careful  palpation.  The  organic  curvature  due  to  Pott's  disease, 
which  is  permanent  and  rigid,  is  to  be  differentiated  from  curvatures  due 
to  false  position  and  muscular  weakness,  such  as  are  associated  with  rickets 
and  other  malnutritions.  The  nonflexibility  of  the  spinal  curvature  of 
Pott's  disease  as  compared  with  the  flexible  curvatures  from  other  causes 
is  one  of  the  important  diagnostic  points.  In  making  this  examination  the 
patient  is  placed  upon  the  table  face  downward,  the  fingers  of  one  hand 
are  now  gently  inserted  between  the  spinal  processes  over  the  curvature; 
with  the  other  hand  grasping  and  lifting  the  ankles  of  the  child,  its  body  is 
bent  backward,  and  as  the  spine  bends  with  the  body  the  finger  inserted 
between  the  spinal  processes  discovers  no  approximation  of  these  processes, 
or,  in  other  words,  the  spinal  curvature  remains  rigid.  In  other  forms  of 
curvature  the  spinal  processes  are  felt  to  close  upon  the  fingers  as  that 
portion  of  the  spine  bends  under  the  backward  movement.  Eetraction  of 
the  head  and  opisthotonos,  such  as  one  sees  in  meningitis  and  certain  other 
nervous  disorders,  may  be  discovered  early  by  placing  thQ  hand  under  the 
head  and  lifting  the  body  of  the  child  while  the  neck  remains  rigid  or  bent 
backward.  In  marked  cases  the  child  may  be  lifted  without  bending  the 
body  by  placing  one  hand  under  the  head  and  the  other  under  the  legs. 

Reflexes. — The  patellar  reflex  is  one  of  the  most  easily  developed 
and  one  of  the  most  important  of  the  deep  reflexes.  It  may  be  elicited  by 
placing  the  child  in  a  sitting  position  with  its  leg  flexed  at  the  knee  and 
hanging  loosely  from  a  chair,  or  in  the  infant  the  leg  may  be  lifted  by  the 
hand  as  the  infant  lies  in  bed,  so  that  the  knee  is  sharply  bent  and  the 
lower  leg  hangs  loosely  over  the  hand.  With  the  child  in  one  or  the  other 
of  these  positions  the  tendon  just  below  the  patella  is  struck  sharply  with 
the  edge  of  the  hand ;  in  response  to  this  the  muscle  contracts  and  the  foot 
is  thrown  quickly  upward.  In  certain  diseases  of  the  nervous  system  this 
reflex  is  absent,  in  others  it  is  exaggerated.  An  exaggerated  patellar  reflex, 
especially  if  unilateral,  is  of  great  value  in  the  late  diagnosis  of  spastic 
4 


32 


EXAMINATION    OF   THE    SICK   CHILD 


palsies  due  to  cortical  cerebral  hemorrhage  in  early  infancy,  and  the  pres- 
ence or  absence  of  this  reflex  is  of  value  in  locating  the  site  of  a  transverse 
myelitis.  Its  absence  on  both  sides  locates  the  myelitis  at  or  below  the  sec- 
ond lumbar  vertebrae.  Its  presence  locates  the  myelitis  above  this  point. 
The  diagnosis  of  the  myelitis  itself  must,  of  course,  depend  upon  the  other 
symptoms  of  this  disease. 

Babinsky^s  Reflex. — This  reflex  is  present  in  some  forms  of  menin- 
gitis and  in  all  conditions  which  interfere  with  the  conducting  power  of 
the  pyramidal  tracts.  It  is  produced  by  drawing  the  tip  of  the  finger  across 
the  plantar  surface  of  the  foot.  It  consists  in  a  marked  hyperextension  of 
the  great  toe  with  a  separation  and  perhaps  extension  of  the  other  toes. 
This  sign  is  of  no  value  in  children  under  two  years  of  age,  since  at  this 


Fig.  4. — Palpating  Spinal  Curvature. 


time  of  life,  by  reason  of  the  lack  of  development  of  the  pyramidal  tracts, 
hyperextension  of  the  great  toe  from  plantar  irritation  is  the  normal  re- 
sponse. Koplik  has  observed  the  Babinsky  reflex  more  commonly  in  tuber- 
culous than  in  other  forms  of  meningitis,  and  Morse  called  special  atten- 
tion to  the  unreliability  of  this  sign  in  young  children. 

Kernig's  Sign. — The  muscular  resistance  at  the  knee  Joint,  which 
makes  it  impossible  to  extend  the  leg  when  the  thigh  is  flexed  at  right 
angles  to  the  body,  is  a  sign  of  meningeal  irritation.  It  is  commonly  found 
in  all  forms  of  meningitis  and  is  sometimes  present  in  meningeal  irritation 
from  acute  toxic  conditions  such  as  pneumonia  and  typhoid  fever. 

Percussion.  ■ — As  Hamill  has  emphasized,  satisfactory  results  can  be  ob- 
tained by  percussion  only  when  the  greatest  care  is  taken  to  see  that  all  the 
conditions  are  favorable.  In  order  to  distinguish  the  shades  of  sound 
elicited,  quiet  surroundings  are  absolutely  necessary.  To  develop  reliable 
percussion  sounds  the  child  should  be  in  proper  position.     To  percuss  the 


PHYSICAL  EXAMINATION 


33 


front  of  the  chest  the  child  should  lie  on  its  back  on  a  firm  bed  or  table; 
the  two  sides  of  its  body  should  be  symmetrically  placed  with  the  face  di- 
rected upward  and  the  spinal  column  straight.  For  percussing  the  back  it 
should  sit  on  the  edge  of  a  table  or  be  held  against  the  chest  of  the  nurse 
with  its  face  over  her  shoulder,  great  care  being  taken  to  have  the  spine 
and  head  straight  and  the  body  of  the  child  as  relaxed  as  possible.  The 
distal  phalanx  of  the  middle  finger  of  one  hand  is  to  be  used  as  a  pleximeter 
and  placed  firmly  against  the  chest  w'all,  with  the  middle  finger  of  the  other 
hand  the  distal  phalanx  thus  placed  is  tapped  quickly  but  gently.  Great 
stress  should  be  laid  on  very  light  percussion.  The  physician  by  experience 
will  learn  the  force  of 
the  stroke  that  serves 
him  to  the  best  purpose. 
The  value  of  the  percus- 
sion note  elicited  at  any 
point  is  judged  largely 
by  comparison  with  other 
percussion  notes  elicited 
in  other  portions  of  the 
chest.  Hamill  justly  lays 
great  stress  upon  these 
details.  He  also  says 
the  percussion  of  the 
chest  of  the  normal  in- 
fant or  young  child 
yields  the  following  re- 
sult?:  "On  the  right, 
from  the  clavicle  to  the 
fourth  rib,  one  elicits 
the  full  normal  pul- 
monary resonance.  Be- 
low this  point,  owing  to 
the  decreased  volume  of 
lung,  and  the  presence 
behind  it  of  the  liver, 

the  sound  becomes  gradually  dull  and  finally  passes  into  the  dull  sound  of 
the  liver  at  the  sixth  rib.  On  the  left  side  there  is  a  relatively  dull  area  be- 
hind and  beneath  the  inner  third  of  the  clavicle,  which  sometimes  extends 
outward  to  the  mid-clavicular  line,  and  always  downward  until  it  fades  into 
the  cardiac  dullness."  If  percussion  is  skilfully  done  much  information 
can  be  obtained  concerning  the  pathological  processes  going  on  in  the  chest 
cavity.  It  is  especially  valuable  in  the  diagnosis  and  differential  diagnosis 
of  diseases  of  the  lungs,  pleura  and  heart.  By  it  also  much  information 
can  be  obtained  concerning  diseased  processes  going  on  in  the  abdominal 
cavity.  Enlargement  of  the  liver  and  spleen,  and  fluids,  and  tumors  in  the 
abdominal  cavity  may  be  mapped  out  by  percussion. 


CU88ION  AND   AUSCULTATION   POSITION. 


34  EXAMINATION    OF   THE    SICK   CHILD 

Auscultation. — The  average  practitioner  obtains  much  more  informa- 
tion by  auscultation  than  he  does  by  percussion.  This  is  partly  due  to  the 
fact  that  much  less  experience  and  skill  is  required  to  obtain  information  by 
auscultation.  The  position  of  the  infant  and  child  should  be  the  same  as 
that  above  described  for  percussion,  as  the  auscultatory  sounds  may  be 
readily  changed  by  position.  A  binaural  stethoscope  with  a  small  bell 
should  be  used,  so  that  every  portion  of  the  chest  wall  including  the  axilla 
may  be  readily  reached.  In  the  auscultation  of  heart  sounds  the  point  of 
greatest  intensity  should  be  sought  for.  This  is  commonly  at  the  apex  or 
the  base.  The  direction  in  which  these  cardiac  murmurs  are  carried  should 
then  be  carefully  traced.  Respiratory  sounds  on  one  side  should  be  com- 
pared with  the  respiratory  sounds  at  the  same  point  over  the  opposite  lung. 
In  interpreting  respiratory  sounds  it  is  important  to  remember  that  the 
expiratory  murmur  is  more  intense  on  the  right  side  beneath  the  clavicle 
and  over  the  spine  of  the  scapula  than  it  is  on  the  left.  The  more  intense 
respiratory  murmur  to  the  right  of  the  sternum  and  beneath  the  clavicle  is 
in  contrast  with  the  area  of  relative  dullness  in  a  somewhat  similar  posi- 
tion on  the  left  side.  It  is  important  also  to  remember  the  rough  inspira- 
tory sound  normally  found  over  the  lungs  of  infants  and  young  children. 
This  so-called  puerile  breathing,  if  slightly  exaggerated,  may  be  mistaken 
for  bronchial  breathing  unless  one  remembers  that  the  normally  rough 
breathing  of  the  infant  is  especially  marked  on  inspiration,  and  the  patho- 
logical bronchial  breathing  is  more  marked  on  expiration.  If  the  physician 
knows  the  normal  heart  and  lung  sounds,  auscultation,  if  carefully  done,  is 
of  the  very  greatest  value  in  the  diagnosis  of  heart  and  lung  diseases. 

SPECIAL  EXAMINATIONS 

Examination  of  Urine  and  Stools. — An  examination  of  the  urine 
should  be  made,  if  possible,  in  every  case;  some  obscure  conditions  may  be 
cleared  up  in  this  way.  It  is  impossible  in  an  individual  case  to  decide 
from  other  symptoms  as  to  the  necessity  for  examining  the  urine.  This 
examination  should  include  the  presence  or  absence  of  bile,  indican,  indol- 
acetic  acid,  albumin,  the  acetone  bodies,  pathological  crystals,  pus,  patho- 
logical epithelium,  blood  and  casts  of  various  kinds. 

Intestinal  discharges  should  be  inspected  as  a  routine  measure  in 
all  cases.  This  is  especially  important  in  children  under  two  years  of  age. 
These  discharges  should  be  seen  by  the  physician,  as  it  is  impossible  for  him 
to  get  accurate  information  concerning  tlieir  character  from  the  descrip- 
tion of  them  given  by  the  nurse.  The  following  points  should  be  observed : 
the  reaction  (if  strongly  alkaline  protein  putrefaction  is  indicated,  if  highly 
acid  carbohydrate  fermentation)  ;  the  consistency — watery,  spongy,  pasty  or 
formed ;  the  color — green,  yellow,  brown,  black  or  mottled ;  the  presence  or 
absence  of  curds  (which  if  small  and  soft  indicate  undigested  fat,  if  large 
and  tough  undigested  casein) — other  undigested  food,  mucus,  blood  and 
intestinal  parasites.     In  some  instances  it  may  be  necessary  to  make  a 


SPECIAL   EXAMmATIONS 


35 


microscopical  or  chemical  examination  of  the  stools  for  the  purpose  of 
determining  the  presence  or  absence  of  blood,  undigested  food,  the  eggs  of 
intestinal  parasites,  tubercle  bacilli  and  pus. 

Talbot  says:  "A  microscopic  examination  of  the  stool  gives  very  accu- 
rate information  about  the  digestion  of  fat.  Two  stains  are  used,  one  on 
each  of  two  coverglass  preparations,  alcoholic  solution  of  Sudan  III^  and 
carbolfuchsin.^  These  stain  the  neutral  fats,  fatty  acids  and  soaps  differ- 
ently.    The  following  table  shows  these  differences: 


Stain 

Neutral  Fat 

Fatty  Acids 

Soapa                  ' 

Sudan  III 

Drops  staining  red 

Drops  staining  red  or  crystals 
which  may  or  may  not  stain 

Do  not  stain 

Carbolfuchsin 

Do  not  stain.     Remain  oily, 
colorless  drops 

Stain  brilliant  red 

Stain  dull  red 

"After  these  two  coverglasses  are  examined  and  the  microscopic  picture 
is  clear,  a  drop  of  glacial  acetic  acid  is  allowed  to  run  under  the  coverglass 
covering  the  Sudan  III  stain,  is  thoroughly  mixed  in,  then  heated  until  ij; 
begins  to  bubble.  Care  should  be  taken  not  to  boil  the  preparation  so  much 
that  all  the  melted  fat  will  run  off  the  slide.  This  process  turns  the  soaps 
and  neutral  fats  into  fatty  acids,  which,  while  warm,  appear  as  large  red- 
stained  drops,  and,  upon  cooling,  crystallize.  This  shows  the  amount  of 
total  fat  in  the  stool,  while  the  first  two  slides  examined  show  the  relative 
proportions  of  neutral  fat,  fatty  acids  and  soaps.  There  is  no  way  of  dif- 
ferentiating neutral  fat  drops  from  fatty  acid  drops  by  Sudan  III;  it  is, 
therefore,  necessary  to  stain  a  second  preparation  with  carbolfuchsin  (see 
table)  which  does  not  stain  neutral  fat  and  does  stain  fatty  acids.  These 
tests  are  very  simple,  quick  and  valuable,  giving  accurate  and  often  surpris- 
ing evidence  concerning  the  digestion  of  fat.  They  should  alwa)'^s  be  used. 
An  excess  of  fat  can  be  easily  determined  and  acted  upon;  absence  of  fat 
very  often  shows  why  the  baby  does  not  gain  and  always  means  that  fat  is 
not  the  cause  of  the  indigestion.  This  rough  method  of  estimating  the 
relative  proportion  of  neutral  fats,  fatty  acids  and  soaps  also  gives  an  idea 
of  the  digestive  functions.  If  there  is  an  excess  of  fat  most  of  which  is 
split  the  digestion  is  normal  and  assimilation  is  abnormal;  if  the  majority 
of  the  fat  is  unsplit  or  only  partially  digested  both  digestion  and  assimila- 
tion are  abnormal." 

Tuberculin  Skin  Reactions. — The  reaction  which  results  from  inoculat- 
ing the  skin  with  Koch's  old  tuberculin  has  in  recent  years  been  very  ex- 
tensively used  in  the  diagnosis  of  concealed  forms  of  tuberculosis.  These 
tests  are  of  special  value  in  childhood,  since  this  is  the  period  of  life  when 
latent  or  concealed  tuberculosis  of  lymphatic  and  other  tissues  is  so  common. 

^  Sudan  III  powder,  95  per  cent,  ethyl  alcohol.     Saturated  solution. 
-  Carbolfuchsin,  such  as  is  used  in   staining  for  tubercle  bacilli.     If  the  stain 
is  too  intense  it  may  be  diluted  with  equal  parts  of  alcohol,  95  per  cent. 


36  EXAMTXATIOX    OF   THE    SICK   CHILD 

The  value  and  limitation  of  these  tests  are  described  in  the  chapter  on 
Tuberculosis.  The  Moro  inunction  test  is  the  simplest  and  the  best  for 
general  use.  In  this  test  an  ointment  consisting  of  equal  parts  of  anhy- 
drous lanolin  and  "old"  tuberculin  is  thoroughly  rubbed  into  a  portion  of 
the  skin  about  the  size  of  a  dollar;  the  abdomen  is  the  site  commonly 
selected.  On  the  opposite  side  of  the  abdomen,  in  a  similar  location,  pure 
lanolin  is  rubbed  into  the  skin  in  the  same  vigorous  manner;  this  is  done 
as  a  control.  A  positive  reaction  is  indicated  by  the  appearance  within 
twelve  or  twenty-four  hours  of  an  eruption  over  the  area  of  skin  into  which 
the  tuberculin  was  rubbed,  while  the  skin  on  the  opposite  side  into  which 
the  lanolin  was  rubbed  remains  normal.  This  eruption  consists  of  small 
papules  surrounded  by  a  red  areola,  so  that  the  whole  area  of  the  spot 
rubbed,  and  perhaps  a  portion  of  the  surrounding  skin,  has  an  erythematous 
flush  in  which  there  is  a  niaculopapular  eruption.  Von  Pirquet's  test  is 
perhaps  slightly  more  sensitive  than  the  Moro  test.  It  consists  in  scari- 
fying the  arm  in  three  places,  several  inches  apart ;  the  scarification  is  made 
as  in  vaccination.  Into  the  middle  scarification  Koch's  "old"  tuberculin  is 
scratched  or  rubbed  with  the  same  technique  used  in  Jennerian  vaccination. 
A  positive  reaction  is  indicated  by  the  appearance,  within  twelve  or  forty- 
eight  hours,  of  an  eruption  of  scattered  papules  within  a  dark,  red  zone, 
which  occurs  in  and  about  the  middle  scarification,  while  the  upper  and 
lower  scarifications  show  no  reaction  whatever.  The  inflammatory  flush  of 
the  skin,  which  results  from  both  the  Moro  and  Von  Pirquet  tests,  begins 
to  subside  within  twenty-four  or  thirty-six  hours  after  their  appearance 
and  thereafter  quickly  disappears.  The  severity  of  this  skin  reaction  is  not 
an  indication  of  the  extent  or  activity  of  the  tuberculous  process.  A  very 
pronounced  reaction  may  be  obtained  in  children  who  show  no  other  signs 
of  tuberculosis,  and  a  negative  reaction  is  commonly  obtained  in  cases 
where  the  tuberculous  process  is  active  and  associated  with  high  fever  and 
other  signs  of  a  destructive  tuberculosis.  The  hypodermic  injection  of 
tuberculin  and  the  dropping  of  a  tuberculin  solution  in  the  eye  will  also 
give  a  prompt  reaction  in  the  latent  and  concealed  forms  of  tuberculosis, 
but  these  tests  have  now  largely  fallen  into  disuse  because  the  Moro  and 
Von  Pirquet  tests  are  simpler,  less  disagreeable  and  are  followed  by  abso- 
lutely no  untoward  results. 

The  chief  objection  to  all  of  these  tuberculin  tests  is  that  they  are  so 
sensitive  that  they  give  a  reaction  in  all  cases  where  there  is  the  slightest 
focus  of  concealed  tuberculosis.  A  negative  reaction  is  of  great  value  in 
excluding  concealed  forms  of  tuberculosis  not  associated  with  fever  and 
other  acute  symptoms.  A  positive  reaction  is  also  of  great  diagnostic  value 
in  children,  but  the  activity  and  extent  of  the  tuberculous  process  must  be 
determined  by  other  signs  and  symptoms.  It  is  evident,  therefore,  that,  of 
these  tuberculin  reactions,  the  least  sensitive  will  be  of  the  greatest  value 
from  a  clinical  standpoint.  The  Moro  test  is  slightly  less  sensitive  than 
the  others  and  for  this  reason  it  is  of  more  practical  value  from  a  clinical 
standpoint. 


PLATE  I. 


The  Moro  Tuberculin  Skin  Reaction. 
(From  Hamill,  Carpenter  and  Cope). 


•v^ 


ri 


SPECIAL   EXAMINATIONS 


37 


Blood  Examinations. — The  ordinary  blood  examination  should  include 
an  estimation  of  the  amount  of  hemoglobin,  the  number  and  character  of 
the  red  blood  corpuscles,  the  color  index,  the  number  of  white  blood  cor- 
puscles and  a  differential  count  in  which  the  relative  percentages  of  the 
various  kinds  of  white  blood  corpuscles  are  given.  Such  an  examination  is 
absolutely  necessary  to  the  diagnosis  of  diseases  of  the  blood  and  of  the 
blood-forming  organs  and  is  of  great  value  in  the  diagnosis  and  prognosis 
of  septic  processes  and  of  some  of  the  acute  infections. 

Lumbar  Puncture  (Quincke). — A  bacteriological  examination  of  the 
cerebrospinal  fluid  obtained  by  lumbar  puncture  is  of  great  value  in  the 
differential  diagnosis  of  the  various  forms  of  meningitis.  The  operation  is 
to  be  performed  with  clean  instruments  under  aseptic  conditions  so  that  the 


Fig.  6. — Position  for  Lumbar  Puncture. 


fluid  when  obtained  will  not  be  contaminated.  In  performing  this  opera- 
tion general  anesthesia,  as  a  rule,  is  not  necessary.  The  patient  is  placed 
on  his  side  with  his  spine  curved  so  as  to  bring  prominently  into  view  the 
spinous  processes,  and  in  this  position  he  is  to  be  firmly  held  by  an  assist- 
ant. The  skin  over  the  site  of  puncture  is  to  be  scrubbed  with  soap  and 
water  and  washed  with  alcohol  and  a  bichlorid  of  mercury  solution.  The 
operator  then,  with  clean  hands,  inserts  between  the  third  and  fourth  lum- 
bar vertebrae  a  clean  trocar  or  cannula,  about  one  millimeter  in  diameter,  and 
by  gentle  pressure  it  is  pushed  directly  inward  for  about  three-fourths  of 
an  inch.  If  it  meets  with  an  obstruction  it  is  to  be  withdrawn  and  rein- 
serted. The  entrance  to  the  spinal  canal  is  noted  by  the  lack  of  resistance 
and  by  the  flow  of  the  fluid  through  the  cannula.  After  the  first  few  drops 
have  escaped,  from  20  to  40  c.  c.  of  cerebrospinal  fluid  is  allowed  to  flow 


38        THERAPEUTICS    OF   INFANCY   AND    CHILDHOOD 

through  the  cannula  and  is  caught  in  a  sterile  test  tube.  The  needle  is  now 
withdrawn,  the  wound  dressed  with  surgeon's  adhesive  plaster  and  the  fluid 
subjected  to  a  careful  bacteriological  examination,  to  determine  if  possible 
the  microorganism  causing  the  disease.  The  point  of  puncture  is  located 
by  an  imaginary  line,  passing  directly  backward  over  the  spine  between  the 
iliac  crests.  With  the  child  in  position,  the  iliac  crests  on  either  side  may 
be  easily  located,  and  the  line  passing  between  these  two  points  directly 
backward  over  the  spine  crosses  the  third  lumbar  spine;  the  needle  is  in- 
serted in  the  interspace  below  this  spinal  process.  This  operation  is  com- 
paratively simple  and  is  attended  with  little  or  no  danger  unless  it  be  post- 
poned until  the  child  is  in  extremis. 

Rontgen-Rays. — The  pictures  produced  by  Eontgen-rays  are  of  the  very 
greatest  value  in  the  accurate  diagnosis  of  a  large  number  of  medical  and 
surgical  conditions,  and  the  diagnostic  field  which  has  been  opened  up  by 
this  method  is  gradually  becoming  wider  and  wider.  They  are  of  special 
value  in  the  diagnosis  of  the  following  conditions:  injuries  and  diseases 
of  bones  and  Joints;  kidney  and  bladder  stones;  foreign  bodies  in  the  in- 
testinal canal,  respiratory  passages  and  other  organs  and  tissues;  diseases 
of  the  heart  and  lungs;  enlargement  of  organs,  such  as  the  thymus  gland, 
kidneys,  liver,  and  deep-seated  lymph  nodes;  collections  of  pus  and  other 
fluids  in  the  pleural  cavity,  the  pericardium,  accessory  sinuses  of  the  face, 
the  abdominal  cavity  and  other  parts  of  the  body. 

Other  Examinations. — There  are  many  other  special  examinations  which 
may  be  necessary  to  clear  the  diagnosis  in  individual  cases,  such  as  the 
Widal  reaction  for  the  differential  diagnosis  of  typhoid  from  other  fevers; 
a  bacteriological  examination  of  the  sputum  for  the  purpose  of  determining 
the  character  of  the  infection  in  diseases  of  the  respiratory  passages;  a 
bacteriological  examination  of  the  throat  to  distinguish  diphtheria  from 
other  exudative  inflammatory  deposits;  a  bacteriological  examination  of  in- 
flammatory exudates  in  the  pleura  and  other  parts  of  the  body,  for  de- 
termining the  causative  organism  which  has  produced  the  infection. 


CHAPTER  IV 
THEEAPEUTICS    OF    INFANCY   AND    CHILDHOOD 

Under  this  heading  may  be  included  all  measures  employed  for  the  cure 
and  prevention  of  disease.  Diet,  especially  during  infancy,  is  one  of  our 
most  important  therapeutic  measures,  but  this  is  elsewhere  discussed.  It 
remains  for  us  here  to  give  an  outline  of  other  methods  of  treatment. 

MEDICINAL  TREATMENT 

Drug  Administration  by  Mouth. — This  is  an  important  part  of  general 
therapeutics.     By  the  administration  of  drugs  a  few  diseases  are  cured; 


MEDICINAL   TEEATMENT  39 

many  others  are  treated  symptomatically  so  that  symptoms  are  relieved,  and 
the  general  course  and  character  of  the  disease  so  modified  that  its  dura- 
tion is  shortened  and  the  chances  for  a  favorable  termination  enhanced. 

In  almost  all  diseases  the  use  of  drugs  is  more  or  less  indicated,  either 
for  their  direct  curative  power,  their  favorable  influence  on  the  course  and 
duration  of  the  disease,  or  their  control  over  disagreeable  symptoms.  Great 
as  is  the  value  of  drugs  skilfully  and  judiciously  administered,  the  unneces- 
sary and  unskilful  giving  of  medicines  is  almost  of  equal  harm.  Drugs 
should  be  given  only  when  there  is  a  decided  probability  that  their  adminis- 
tration will  do  the  patient  more  good  than  harm.  This  rule  of  action  is 
especially  applicable  to  children  under  two  years  of  age.  In  every  sick 
infant,  whatever  may  be  the  cause  of  its  illness,  the  probability  of  gastro- 
intestinal complications  should  be  kept  in  mind.  It  is  most  important  that 
the  physician  in  giving  drugs,  during  this  period  of  life,  should  exercise  the 
greatest  precaution  lest  he  produce  some  gastrointestinal  disturbance  and 
thereby  add  a  serious  complication  to  the  existing  malady.  This  precau- 
tion is  especially  important  in  the  treatment  of  acute  diseases  of  the  res- 
piratory passages  and  other  acute  infections.  In  these  conditions  I  believe 
that  infants  are  unwisely  and  unnecessarily  medicated  with  opium,  coal- 
tar  products,  nauseating  syrups,  such  as  ipecac  and  squills,  and  irritating 
ammonia  preparations;  all  of  which  are  of  little  or  no  value  in  the  treat- 
ment, but,  on  the  other  hand,  are  capable  of  producing  gastrointestinal  and 
other  complications  which  add  a  gravity  to  these  diseases  which  they  would 
not  otherwise  have  had.  In  children  under  two  years  of  age,  and  perhaps 
I  may  say  in  children  of  all  ages,  the  physician  before  prescribing  a  drug 
should  feel  assured  that  there  is  a  reasonable  probability  that  the  drug  will 
exercise  a  favorable  influence  on  the  disease  without  producing  harm  in 
some  other  direction. 

Palatable  medication  is  one  of  the  keynotes  to  success  in  pediatric  prac- 
tice. It  is  important  that  the  most  cordial  and  friendly  relationship  should 
exist  between  the  physician  and  his  little  patient.  Without  this  the  physi- 
cian falls  short  of  having  his  visits  and  his  ministrations  accomplish  the 
greatest  possible  amount  of  good  to  the  child.  The  degree  of  friendship 
which  exists  between  the  physician  and  his  small  patients  is  largely  a  mat- 
ter of  his  own  making.  If  in  his  absence  he  instructs  the  mother  to  use 
her  powerful  influence  over  the  child,  to  educate  it  into  the  belief  that  the 
physician's  coming  is  an  event  to  be  looked  forward  to  with  pleasure,  and 
if  when  the  physician  makes  the  visit  he  exercises  the  proper  tact  in  his 
association  with  the  child  and  uses  his  best  judgment  in  the  selection  of 
proper  remedies,  which  are  either  pleasant  to  the  taste  or  their  disagree- 
ableness  so  disguised  that  the  child  will  not  associate  anything  unpleasant 
with  the  taking  of  medicines,  then  the  relationship  of  the  child  and  physi- 
cian will  be  such  that  he  can  make  his  examinations  and  prescribe  his  treat- 
ment without  engendering  the  child's  ill-will. 

The  physician  should  remember  that  pleasant  medication  appeals  to  the 
mother  almost  as  much  as  it  does  to  the  child.     The  forcing  of  disagreeable 


40 


THERAPEUTICS    OP   INFANCY   AND    CHILDHOOD 


medicines  down  the  throat  of  a  screaming  and  struggling  child  is  an  opera- 
tion which  neither  the  mother  nor  the  child  will  submit  to  for  any  great 
length  of  time.  A  procedure  of  this  kind  in  children  who  are  acutely  ill, 
and  especially  in  nervous  children,  exercises  a  very  unfavorable  influence 
on  the  course  of  the  disease,  and  the  drug  that  produces  more  good  than 
harm  under  these  conditions  must  have  a  specific  curative  influence  on  the 
disease.  While  much  stress  is  laid  upon  the  necessity  for  pleasant  medica- 
tion and  the  tactful  handling  of  the  child  so  that  a  cordial  relationship 
may  exist,  yet  in  following  this  line  of  action  it  is  most  important  that  the 
physician  should  not  fail  to  make  necessary  examinations  because  they  are 
unpleasant  to  the  child ;  nor  should  he  omit  to  give  it  some  drug  having  a 
specific  curative  influence,  such  as  quinin,  mercury  or  antitoxin,  simply 
because  by  its  administration  he  may  engender  the  ill-will  of  the  child. 

Opium  is  rarely  to  be  administered  to  infants  and  children  under  two 
years  of  age.  It  may  very  occasionally  be  necessary  to  prescribe  it  during 
the  second  year  of  life  for  severe  pain,  such  as  occurs  in  earache.  It  should 
always  be  given  with  great  caution  and  in  small  doses  to  children  under 
five  years  of  age. 

Syrups  of  all  kinds  are  contraindicated  in  infancy  and  are  seldom  neces- 
sary in  children  under  five  years  of  age.  The  only  exception  to  this  rule 
is  perhaps  in  those  cases  where  emetics  are  urgently  indicated.  As  a 
vehicle  for  other  medicines,  glycerin,  essence  of  pepsin  and  elixir  of  lactated 
pepsin  are  just  as  palatable  as  syrups,  and  are  not  as  likely  to  disturb  the 
stomach  and  cause  intestinal  fermentation.  Quinin  may  be  given  in  the 
form  of  euquinin  or  mixed  with  powdered  chocolate  to  young  children; 
older  children  may  take  it  in  the  form  of  pills  and  capsules. 

The  following  table  gives  the  average  dose  and  most  common  therapeutic 
indications  of  the  drugs  most  frequently  used  in  the  treatment  of  diseases 
in  children  under  three  years  of  age : 


Drugs 


Dose  at 
1  Year 


Dose  at 
3  Years 


Therapeutic  Indications 


Antipyrin 

Aspirin 

Belladonna  tinct 

Bismuth  subnitrate  .  .  . 

Calomel 

Cascara  sagrada  ext. . . 

(aromatic) 
Castor  oil 

Chalk  comp.  mixt .... 

Chloral  hydrate 

Codliver  oil 

Diastase 

(thick  malt  ext.) 

Digitalis  tinct 

Guaiacol  carbonate  . . . 

Glonoin  (nitroglycerin) 

Hydrochloric  acid  dil . . 
Iron  sach.  carb 


gr. 

J^-1 

HX- 

H-i 

m 

y2-i 

fix. 

2-5 

fX. 

H-l 

m 

5-10 

dr. 


dr.      1 
gr.       1-2 

dr.  J4 

dr.  ^ 


400 
m        1 
gr.       1 


1-2 
1-3 
1-2 
3-10 
1-2 
10-20 


dr.      1-2 


1-2 
2-3 
1 


2-3 
1       1 


300  200 
m       2-3 
gr.       2 


Nervous  symptoms  associated  with  fever. 
Influenza,  fever,  nervous  symptoms. 
Coryza,  pharyngitis,  bladder  irritation. 
Gastrointestinal  irritation,  diarrhea. 
Gastrointestinal  disorders,  febrile  diseases. 
Constipation. 

As  a  preliminary  cathartic  in  gastroin- 
testinal disorders;  acute  febrile  dis- 
eases. 

Gastrointestinal  irritability. 

Convulsive  disorders. 

As  a  general  tonic  in  nutritional  disorders, 
such  as  rickets  and  tuberculosis. 

As  a  digestive  and  tonic  in  nutritional 
disturbances,  such  as  chronic  intestinal 
indigestion. 

As  a  heart  tonic  in  cardiac  and  other  dis- 
eases. 

Gastrointestinal  disorders,  tuberculosis. 

In  condition  of  collapse  and  cardiac 
failure. 

Gastrointestinal  disorders. 
Anemic  conditions. 


MEDICINAL   TREATMENT 


41 


Drugs 


Dose  at 
1  Year 

Dose  at 
3  Yeabs 

dr. 

M-1 

dr. 

1-2 

dr. 
gr. 

1 

10-20 

dr. 

gr. 

1-2 
30 

gr. 

V2 
1 

gr. 

y2-i 

1      1 

gr. 

150 
1 

gr. 

100  50 

1 

gr. 
m 

100 
5-10 

gr. 
m 

40 
10-20 

dr. 

V2 

dr. 

1 

gr. 
gr. 

2-3 

gr. 
gr. 

1-2 
3-5 

gr. 
gr. 
gr. 

1 
1 

gr. 
gr. 
gr. 

2-3 
1-2 

3-5 

gr. 

10-20 

gr. 

30-60 

gr. 

1-2 

gr. 

2Ht 

gr. 
gr. 
gr. 

1-2 
2-3 

gr. 
gr. 
gr. 

3-5 
5-10 

gr. 
gr. 
gr. 

2-3 

1 

5-10 

gr. 
gr. 
gr. 

5 

2-3 
20-30 

gr. 

1 

gr. 

2 

m 

1 

m 

2 

1 

1 

gr. 
gr. 

500 

gr. 
gr. 

200 
1-3 

Therapeutic  Indications 


Ipecac  syrup 

Magnesia,  milk  of  .  . 
Magnesium  sulphate 

Mercury  with  chalk 

Mercury  bichlorid  .  . 

Morphin  sulphate  .  . 

Paregoric 

Pepsin  essence 

Phenacetin 

Potassium  bromid  .  . 

Potassium  chlorate  . 
Quinin  sulphate  .  .  .  . 

Euquinin 

(tasteless  quinin) 
Rochelle  salts 

Salol 

Santonin 

Sodium  benzoate  .  .  . 
Sodium  bicarbonate  . 

Sodium  bromid 

Sodium  iodid 

Sodium  phosphate  .  . 

Sodium  salicylate  . . . 

Strophanthus  tinct  . . 

Strychnin  sulphate  . 
Urotropin 


As   an   emetic    in    spasmodic    croup    and 

other  conditions. 
As  a  laxative  and  stomach  sedative. 
As    a    cathartic     in   nephritis  and    other 

conditions. 
Syphilis  and  gastrointestinal  disorders. 

Syphilis. 


Severe  convulsive  disorders. 
(Given  hypodermically) 

Earache  and  other  severe  pain;   rarely  in 
intestinal  disorders. 

Digestive  disorders,  as  vehicle  for  other 
medicines. 

Fever   and  associated  nervous  symptoms. 

Nervous  symptoms  and  as  a  cough  seda- 
tive. 

Stomatitis. 

Malaria,  influenza  and  as  a  general  tonic* 

Malaria,  influenza  and  as  a  general  tonic. 

As  a  cathartic  in  nephritis,  enteritis  and 

other  conditions. 
Gastrointestinal    diseases,    influenza    and 

febrile  conditions. 
Intestinal  worms. 

Influenza  and  other  febrile  conditions. 
Stomach  disorders  and  autointoxications 

(acidosis). 
Nervous  symptoms,  cough  sedative. 
Syphilis. 
As  a  laxative  in  gastrointestinal  disorders, 

autointoxications  and  other  conditions. 
Intestinal  fermentation,  rheumatism  and 

tonsillitis. 
Cardiac    disease,    pneumonia    and    condi- 
tions producing  heart  failure. 
Pneumonia,    myocarditis    and    conditions 

requiring  a   respiratory  stimulant    and 

general  tonic. 
Pyelocystitis  and   conditions   requiring    a 

urinary  antiseptic. 


Inuiictions. — The  value  of  this  method  of  administering  drugs  to  in- 
fants and  children  is,  I  believe,  not  fully  appreciated  by  the  general  prac- 
titioner. In  the  following  outline  I  have  quoted  freely  from  a  paper^  on 
this  subject  which  I  published  some  years  ago. 

Inunctions  are  very  much  more  efficacious  in  the  treatment  of  disease  in 
young  children  than  they  are  in  adults,  for  the  following  reasons : 

1.  In  infants  and  young  children  the  surface  of  the  skin,  in  proportion 
to  the  body  weight,  is  from  four  to  six  times  greater  than  in  adults.  This 
brings  the  whole  blood  and  lymph  circulation  in  closer  communication  with 
the  blood  vessels  and  lymphatics  of  the  skin,  and  makes  it  possible  for 
drugs  whicli  are  rubbed  into  the  skin  to  pass  quickly  through  the  body  and 
make  their  appearance  in  the  urine,  feces,  bronchial  mucus  and  other  excre- 
tions. 

2.  In  infants  and  young  children  the  vasomotor  mechanism  is  much 
more  responsive  to  reflex  stimuli  than  it  is  in  adults,  and  for  this  reason 
the  capillary  circulation  of  the  skin  is  made  much  more  active  by  the  appli- 
cation of  heat  and  friction,  as  in  the  giving  of  inunctions.     This  facilitates 


'  Amer.  Jour,  of  Med.  Sciences,  Jan.,  1909. 


42         THERAPEUTICS    OF   INFANCY   AND    CHILDHOOD 

absorption  and  the  ready  introduction  of  medicines  into  the  general  cir- 
culation. 

3.  All  lymphatic  structures,  including  those  of  the  skin,  are  relatively 
more  active  and  functionally  more  important  in  the  young  child  than  they 
are  in  the  adult.  This  facilitates  the  ready  introduction  of  medicines 
through  the  skin  into  the  lymphatic  circulation. 

4.  In  infants  and  young  children  nutritional  problems  are  of  vastly 
greater  importance  than  they  are  in  the  adult,  and  for  this  reason  it  is  of 
the  utmost  importance  that  the  stomach  and  gastrointestinal  canal  should 
be  kept  in  the  best  possible  condition;  consequently  all  drugs  that  can  be 
advantageously  administered  in  some  other  manner  should  be  kept  out  of 
the  stomach.  This  is  especially  true  of  drugs  which  are  intended  to  influ- 
ence general  metabolism  and  to  act  upon  diseased  tissues  remote  from  the 
gastrointestinal  canal. 

5.  The  disorders  which  can  be  treated  most  satisfactorily  by  inunctions, 
such  as  diseases  of  the  lymphatic  structures  and  respiratory  passages,  are 
much  more  common  and  much  more  severe  in  infants  and  young  children 
than  they  are  in  adults.  This  fact  very  materially  enhances  the  relative 
importance  of  the  inunction  treatment  at  this  age. 

6.  Experiments  demonstrate  that  certain  medicines  may  be  introduced 
into  the  circulating  media  of  the  body  with  great  facility  by  inunctions, 
and  that  this  result  is  more  readily  accomplished  in  infants  and  young 
children  than  it  is  in  adults. 

In  the  giving  of  inunctions  the  following  technique  should  be  observed. 
The  skin  of  the  chest  and  abdomen  must  be  carefully  washed  with  soap  and 
warm  water,  and  hot  moist  towels  applied  for  a  few  minutes  to  warm  and 
redden  the  skin.  One  drachm  of  the  ointment  should  then  be  very  care- 
fully and  gently  rubbed  in,  for  a  period  of  five  or  ten  minutes. 

By  this  method  I  have  demonstrated  that  guaiacol,  iodin,  oil  of  winter- 
green  and  salicylic  acid  can  be  readily  rubbed  through  the  skin,  appearing 
in  the  urine  of  the  child  from  one  and  one-half  to  two  hours  after  its  appli- 
cation, thus  showing  that  these  drugs  have  passed  through  the  blood  and 
circulating  media  of  the  child,  and  have  come  in  contact  with  its  organs 
in  every  part  of  the  body.  The  inunction  method  therefore  is  eminently 
fitted  for  the  administration  of  these  drugs  in  all  diseases  where  they  are 
indicated.  Guaiacol,  given  in  this  way,  may  be  used  in  the  treatment  of 
tuberculosis,  influenza,  bronchitis,  bronchopneumonia  and  all  diseases  of 
the  respiratory  passages,  and  should  to  a  large  extent  take  the  place  of  such 
expectorants  as  ammonia,  squills,  ipecac,  and  antimony.  These  latter 
drugs  are  not  only  of  little  or  no  value  in  the  treatment  of  these  diseases 
in  infants,  but  they  are  capable  of  producing  grave  complications  on  the 
part  of  the  gastrointestinal  organs.  Iodin  administered  by  inunction  is  of 
positive  value  in  the  treatment  of  late  syphilis,  chronic  glandular  enlarge- 
ments and  subacute  and  chronic  diseases  of  the  respiratory  passages.  Oil 
of  wintergreen  and  salicylic  acid,  given  by  inunction,  are  very  valuable  in 
the  treatment  of  muscular  rheumatism,  acute  and  chronic  articular  rheu- 


OTHER    METHODS    OF    TREATMENT  43 

matism,  chorea,  tonsillitis,  and  endocarditis.  The  inunction  method  of  ad- 
ministering mercury  (blue  ointment)  has  long  been  recognized  as  the  safest 
and  best  method  of  administering  this  drug  in  the  treatment  of  syphilis  in 
young  infants,  and  requires  no  elaboration  here.  Colloidal  silver,  within 
the  past  few  years,  has  been  administered  hypodermically,  by  the  stomach, 
and  by  inunction  in  the  treatment  of  various  forms  of  localized  and  general 
septicemias.  The  profession  as  a  whole,  I  think,  has  come  to  recognize 
that  this  is  a  most  valuable  adjunct  in  our  treatment  of  septicemia,  and  I, 
for  one,  after  a  large  experience  extending  over  a  number  of  years,  am 
firmly  convinced  of  its  efficacy.  •  In  acute  enlargement  of  the  lymphatic 
tissues  of  the  neck,  which  may  follow  scarlatinal,  diphtheritic  and  other 
forms  of  tonsillitis,  I  believe  that  this  remedy,  in  the  form  of  unguentum 
Crede,  properly  rubbed  into  the  surrounding  lymphatic  tissues,  is  of  very 
great  value  in  preventing  the  spread  of  the  disease  and  in  controlling  the 
localized  sepsis.  This  drug  can  be  given  more  efficaciously  to  infants  and 
young  children  by  inunction  than  in  any  other  manner,  and  its  value  in 
combating  general  and  localized  sepsis  is  much  greater  in  infants  and  chil- 
dren than  it  is  in  adults. 

Guaiacol,  iodin,  oil  of  wintergreen,  and  salicylic  acid,  for  inunction 
purposes,  should  be  combined  with  anhydrous  lanolin  in  the  proportion  of 
one  drachm  to  the  ounce,  and  the  dosage  of  the  ointment  thus  prescribed 
should  be  one  small  level  teaspoonful  thoroughly  rubbed  into  the  skin  once 
or  twice  in  twenty-four  hours.  Unguentum  Crede  should  be  given  in  the 
same  dosage  at  least  twice  a  day  for  a  period  of  three  or  four  days,  and  it 
is  most  important  that  it  should  be  applied  over  a  large  surface  of  the 
body  and  should  be  thoroughly  rubbed  in. 

OTHER  METHODS  OF  TREATMENT 

The  giving  of  medicines  is  a  comparatively  small  part  of  the  physician's 
duty.  The  questions  of  prophylaxis,  diet,  general  hygiene,  hydrotherapy, 
and  special  methods  of  treatment  are  more  important  than  drug  giving 
except  in  those  comparatively  few  diseases  for  which  we  have  specific  medi- 
cation. The  giving  of  drugs  should  be  considered  as  a  valuable  adjunct  to 
other  methods  of  treatment.  This  is  especially  true  in  the  gastrointestinal, 
the  respiratory  and  the  acute  infectious  diseases,  which  make  the  vast 
majority  of  the  illnesses  of  infancy  and  childhood.  It  is  not  my  desire  to 
belittle  the  importance  of  drug  giving,  but  rather  to  emphasize  the  relative 
importance  of  other  methods  of  treatment. 

Fresh  Air. — Fresh  air  is  one  of  the  most  important  curative  agents  we 
have  for  the  treatment  of  disease.  As  Northrup  has  said,  we  mean  by 
fresh  air  outdoor  air,  cool,  flowing  air,  that  is  to  say,  the  very  freshest  air 
which  the  child  can  obtain  in  the  location  in  which  it  is  being  treated.  The 
outdoor  air  which  may  be  obtained  on.  porches,  and  which  comes  into  the 
sickroom  through  wide-open  windows  even  in  the  downtown  tenement  dis- 
tricts of  our  large  cities^  is  better  than  the  indoor  air,  but  it  is  not  as  good 


44        THERAPEUTICS    OF   INFANCY   AND   CHILDHOOD 

as  the  outdoor  air  which  can  be  obtained  in  the  suburbs  of  our  cities  and 
in  the  surrounding  country,  and  it  is  nothing  like  as  good  as  the  pure,  open 
air  of  the  mountains,  seashore,  and  other  locations  far  removed  from  the 
contaminating  influences  of  cities.  In  the  treatment  of  gastrointestinal 
and  respiratory  diseases  the  curative  influence  of  pure,  fresh,  flowing  air 
is  of  far  greater  value  than  drugs,  and  it  is  also  of  prime  importance  as  a 
remedy  in  the  treatment  of  almost  all  diseases  of  infancy  and  childhood. 
If  the  physician  but  realizes  the  importance  of  fresh,  pure  air  as  a  thera- 


FiQ.  7. 


-Fkesh-Air  Ward  Established  by  the  Author  at  the  Cincinnati  Hospital  in 

1898. 


peutic  agent,  his  own  common  sense  and  judgment  will  direct  him  in  ar- 
ranging the  details  for  the  carrying  out  of  this  treatment.  As  Northrup 
has  emphasized,  this  remedy  should  be  given  in  large  doses  and  throughout 
the  whole  of  the  twenty-four  hours,  but  in  doing  this  the  physician  must 
so  instruct  the  mother  and  the  nurse  in  such  details  as  clothing,  bedding 
and  the  location  of  the  patient,  either  in  the  open  or  in  rooms  with  wide- 
open  windows,  that  while  the  child  is  getting  the  required  amount  of  fresh 
air  it  may  be  kept  warm  in  winter  and  cool  in  summer.  In  the  chapter  on 
Respiratory  and  Gastrointestinal  Diseases  further  details  as  to  this  treat- 
ment are  given. 

Hydrotherapy. — Hydrotherapy  in  its  various  forms  is  one  of  the  most 
valuable  curative  agents  we  have  in  the  whole  range  of  therapeutics.  When 
water  is  applied  to  the  surface  of  the  body  it  reduces  the  temperature  by 
abstracting  heat  and  promoting  evaporation;  it  stimulates  the  skin  to  in- 
creased activity ;  it  acts  kindly  in  controlling  nervous  symptoms,  and,  above 


OTHER    METHODS    OF    TREATMENT  45 

all,  it  has  a  general  tonic  effect,  stimulating  nutritional  processes.  In  this 
it  differs  markedly  from  medical  antipyretics. 

Tub-baths. — Tub-baths  have  a  wide  range  of  applicability  in  the  treat- 
ment of  diseased  conditions  in  infancy  and  childhood.  Children,  however,  do 
not  bear  very  cold  tub-baths  as  well  as  adults,  their  young  nervous  systems 
are  shocked  by  the  sudden  application  of  cold,  and  they  do  not  readily  react 
from  the  cold  bath.  It  is  advisable,  therefore,  to  begin  with  a  temperature 
of  100°  F.  and  gradually  add  cold  water  until  the  temperature  of  the  bath  is 
reduced  to  from  80°  to  90°  F.,  according  to  the  age  of  the  child.  In 
infants  it  is  rarely  necessary  to  reduce  the  temperature  of  the  water  below 
90°  F.  In  older  children  it  may  be  reduced  to  80°  F.  The  patient  should 
remain  in  the  bath  from  five  to  ten  minutes  and  then  be  rubbed  dry  and 
returned  to  bed.  This  remedy  is  especially  indicated  in  the  gastrointes- 
tinal diseases  of  infancy  and  is  also  of  value  in  the  treatment  of  typhoid 
fever,  pneumonia,  and  other  diseases  in  which  the  temperature  runs  high 
and  is  associated  with  nervous  symptoms. 

Sponge  Baths. — These  baths,  when  properly  applied,  reduce  the  tem- 
perature, quiet  the  nervous  system,  promote  sleep,  and  have  a  tonic  effect 
upon  nutritional  processes.  They  have  much  the  same  range  of  applica- 
tion from  the  therapeutic  standpoint  as  the  tub-bath.  While  somewhat 
less  efficacious  than  the  tub-bath,  they  have  the  advantage  of  being  more 
easily  administered  and  of  producing  less  shock  and  excitement  to  the 
nervous  system.  In  their  application  a  rubber  sheet  should  protect  the  bed, 
and  on  this  the  child,  after  having  its  clothing  removed,  is  placed  between 
two  blankets.  The  entire  body  of  the  child  is  then  sponged  with  water  at 
80°  F.  containing  5  or  10  per  cent,  of  alcohol.  During  the  sponging  process, 
which  may  be  continued  for  ten  minutes,  the  parts  of  the  body  not  being 
sponged  are  to  be  covered,  so  as  to  prevent  unnecessary  chilling  of  the  body. 
The  therapeutic  effects  of  this  measure  are  due  not  only  to  the  application 
of  cold  water  to  the  surface  of  the  body,  but  to  the  rapid  evaporation  which 
is  thereby  promoted. 

Cold  Packs. — This  is  a  measure  used  for  the  same  therapeutic  purposes 
as  the  tub  and  sponge  baths.  It  has  its  widest  range  of  applicability,  how- 
ever, in  older  children.  It  is  a  very  effective  measure  for  the  reduction  of 
high  temperatures.  The  body  of  the  child  is  surrounded  with  a  sheet 
wrung  out  of  water  at  about  90°  F.,  and  over  this  sheet,  which  clings  closely 
to  the  child's  bod}'^,  ice  is  rubbed.  This  procedure  may  be  continued  for 
from  ten  to  twenty  minutes,  depending  upon  the  influence  which  the  cold 
pack  has  upon  the  rectal  temperature  and  upon  the  general  condition  of 
the  child.  During  this  process  an  icebag  should  be  applied  to  the  head. 
This  bath  may  be  modified  by  sprinkling  the  sheet  with  cold  water  from 
time  to  time,  and  fanning  the  body  of  the,  child  so  as  to  promote  evapora- 
tion. Following  these  measures,  the  child  is  to  be  wrapped,  sheet  and  all, 
in  a  blanket,  a  warm  water  bottle  placed  to  its  feet,  while  the  icebag  to 
the  head  is  to  be  continued.  After  one-half  hour  the  child  is  to  be  dried 
and  returned  to  its  bed. 


46         THERAPEUTICS    OF   INFANCY   AND    CHILDHOOD 

The  cold  pack,  cold  sponging,  or  tub-bath  may  be  repeated  at  intervals 
of  from  four  to  eight  hours  if  necessary  for  the  control  of  the  temper- 
ature. It  should,  however,  be  remembered,  as  I  have  emphasized  in  the 
chapter  on  Fever,  that  children  bear  moderate  and  even  high  temperatures, 
as  a  rule,  without  serious  inconvenience,  and  that  unless  the  fever  continues 
high  and  is  associated  with  nervous  and  other  symptoms  it  is  not  advisable 
to  be  too  energetic  in  our  efforts  to  reduce  temperature.  Where  temper- 
ature reduction,  however,  is  indicated  as  a  therapeutic  measure  hydro- 
therapy in  one  of  the  forms  above  described  is  to  be  preferred  to  medical 
antipyretics. 

Icecap. — Cold  applied  to  the  head  in  the  form  of  an  icecap  is  a  simple 
and  effective  measure  for  reducing  temperature,  relieving  headache  and 
quieting  general  nervous  symptoms.  The  icebag  is  of  great  value  in  the 
treatment  of  sunstroke,  meningeal  inflammation,  acute  inflammatory  con- 
ditions of  the  heart  and  its  membranes,  appendicitis,  acute  parenchymatous 
tonsillitis,  and  in  acute  localized,  congestive  and  inflammatory  lesions  in 
various  parts  of  the  body.  In  very  young  and  delicate  infants  it  should 
be  cautiously  applied,  but  apart  from  this  it  is  a  comparatively  safe  meas- 
ure, productive  of  much  good  and  rarely  followed  by  untoward  symptoms. 

Cold  Compresses. — Cold  compresses,  made  by  wringing  a  towel  out  of 
water  of  75°  or  80°  F.,  and  covering  it  with  dry  flannel,  has  the  same 
therapeutic  indications  as  the  icebag.  This  measure  is  sometimes  of  con- 
siderable advantage  in  inflammatory  diseases  such  as  tonsillitis,  pneumonia, 
pleurisy  and  endocarditis. 

Hot  Baths. — The  hot  bath  is  of  great  therapeutic  value  in  the  treat- 
ment of  uremia,  infantile  convulsions,  delirium  and  coma.  It  also  has 
a  very  soothing  and  tonic  effect  in  bronchopneumonia.  It  is  one  of  our 
most  effective  measures  for  eliminating  toxins  in  the  acute  infectious  dis- 
eases and  in  the  various  forms  of  autointoxication.  The  child  should  re- 
main in  water  of  110°  F.  for  from  five  to  twenty  minutes,  and  should  then 
be  wrapped  in  a  hot  blanket  for  one-half  hour.  Following  this  it  should  be 
thoroughly  dried  and  returned  to  bed. 

Hot  Compresses. — Hot  compresses  are  of  great  therapeutic  value  in 
muscular  rheumatism  (lumbago),  neuralgic  headaches  and  other  super- 
ficial neuralgias,  abdominal  pain  and  localized  inflammations.  They 
should  be  applied  by  wringing  towels  out  of  very  hot  water  and  placing 
these  as  hot  as  they  can  be  borne  to  the  affected  part.  The  hot  compress 
may  then  be  covered  with  oiled  silk  and  held  in  position  with  a  dry  towel. 

Salt-baths. — Salt-baths  are  of  some  therapeutic  value  in  the  treatment 
of  rickets  and  other  malnutritions.  A  pound  of  salt  should  be  added  to 
six  gallons  of  water  at  body  temperature.  The  bath  should  last  for  ten 
or  fifteen  minutes  and  should  be  followed  by  vigorous  rubbing  or  gentle 
massage ;  one  such  bath  in  twenty-four  hours  is  sufficient. 

Rectal  Irrigations. — Rectal  irrigations  with  cool  water  are  of  value  in 
reducing  the  temperature  of  infants  suffering  from  heat  stroke  and  gastro- 
intestinal disorders.     A  double  rectal  tube  which  permits  of  an  in-  and  out- 


OTHER    METHODS    OF    TREATMENT 


47 


flow  and  which  can  be  passed  well  beyond  the  internal  sphincter  is  to  be 
used.  In  the  beginning  the  temperature  of  the  water  should  be  about 
90°  F.,  and  should  be  gradually  reduced  to  60°  F.  The  irrigation  may  last 
over  a  period  of  ten  minutes. 

Water  Taken  by  Mouth. — Water  taken  by  the  mouth  reduces  the 
temperature  and  is  by  far  the  simplest  and  best  diuretic  and  diaphoretic. 
It  is  of  the  very  greatest  value  during  the  first  forty-eight  hours  in  the 
treatment  of  all  acute  gastrointestinal  diseases  of  infancy.  It  is  indicated 
in  all  the  acute  infectious  diseases,  especially  scarlet  fever,  and  is  of  value 
in  the  treatment  of  all  febrile  conditions.     It  is  of  value  in  constipation, 


Fia.  8. — Hypodebmoclysis. 


functional  and  nervous  disorders,  and  all  forms  of  autointoxication.  Dur- 
ing the  first  year  of  life  the  infant,  as  a  rule,  gets  a  sufficient  quantity  of 
water  in  its  food,  but,  should  it  be  necessary  to  cut  down  the  food  during 
this  period  of  life,  the  deficiency  should  be  made  up  by  the  addition  of 
water.  In  infancy  and  childhood  too  little  attention  is  given  to  the  value 
of  water  in  the  conditions  above  named.  It  should  be  prescribed  as  any 
other  remedial  agent  in  all  toxic  and  febrile  diseases.  Ice  is  a  remedy  of 
value  in  relieving  irritability  of  the  stomach,  in  allaying  thirst,  and  in 
promoting  the  general  comfort  of  the  patient  in  febrile  and  gastrointestinal 
diseases,  where  for  some  reason  water  cannot  be  given  in  quantities  suffi- 
cient to  meet  the  demands  of  the  patient.  The  ice  in  these  cases  should  be 
held  in  the  mouth  until  it  melts.  In  young  infants  and  children  it  may  be 
5 


48 


THERAPEUTICS    OF   INFANCY   AND    CHILDHOOD 


necessary  to  inclose  the  ice  in  a  piece  of  gauze  to  prevent  them  from  swal- 
lowing ii. 

Hypodermoclysis. — Hypodermoclysis,  or  the  introduction  into  the  sub- 
cutaneous tissue  of  a  0.6  per  cent,  common  salt  solution,  is  the  most  effective 
general  stimulant  and  diuretic  in  all  cases  in  which  the  body  media  is  defi- 
cient in  fluids.  It  is  especially  indicated  in  the  profound  prostration  asso- 
ciated with  acute  gastrointestinal  disorders  (cholera  infantum),  severe 
cases  of  recurrent  vomiting  and  severe  hemorrhage.  It  may  also  be  of 
value  in  uremia,  cardiac  failure,  and  in  all  cases  where  a  powerful  stimu- 
lant and  diuretic  is  urgently  indicated.  One  per  cent,  of  bicarbonate  of 
soda  may  be  added  to  this  salt  solution  in  "recurrent  vomiting"  and  other 
conditions  where  it  is  desirable  to  counteract  an  acidosis.     The  favorite 

sites  for  this  injec- 
tion are  under  the 
breast  and  the  loose 
subcutaneous  tissue  of 
the  back  and  abdo- 
men. The  salt  solu- 
tion should  be  sterile 
and  should  be  intro- 
duced through  a  sterile 
needle  under  full  asep- 
tic precautions.  In  in- 
fants and  children 
from  six  to  ten  ounces 
may  be  introduced  at 
one  time.  If  this  is 
quickly  absorbed  the 
injection  may  be  re- 
peated, if  necessary, 
within  six  or  eight 
hours.  The  same 
strength  of  lukewarm 
salt  or  soda  solution  in  cases  of  persistent  vomiting  may  be  of  great  value 
when  introduced  through  a  soft  catheter  into  the  colon,  where  it  is  readily 
absorbed.  In  this  procedure  the  catheter  may  remain  in  position  and  the 
fluid  be  allowed  to  slowly  escape  by  the  drop-method  or  small  injections 
may  be  repeated  from  time  to  time. 

Nasal  Douche. — Washing  out  the  throat,  nose,  and  pharynx  with  a  mild 
alkaline  antiseptic  solution  is,  as  Caille  has  emphasized,  a  measure  of  great 
prophylactic  and  curative  value  in  diseases  of  these  parts.  The  prophy- 
lactic value  of  this  process  in  the  prevention  of  all  contagious  diseases 
which  affect  the  throat  and  respiratory  passages,  as  well  as  of  many  other 
diseases,  is  not  fully  appreciated  by  the  medical  profession.  In  washing 
out  the  nasopharynx  the  child  should  sit  upright,  with  its  head  inclined 
slightly  over  a  basin.     The  mother  or  nurse,  with  an  all-soft  rubber  nose 


Fig.  9. — Position  fob  Nasal  Douchino. 


OTHER    METHODS    OF    TREATMENT  49 

syringe,  slowly  injects  the  alkaline  solution  backward  through  the  nose. 
By  this  procedure  some  of  the  solution  comes  out  of  the  other  nostril  and  a 
portion  of  it  is  carried  downward  through  the  pharynx  into  the  mouth  and 
is  expectorated  by  the  child  into  the  basin.  The  direction  of  the  tip  of  the 
syringe  which  enters  the  nostril  should  be  almost  directly  backward.  By 
this  method  mucus  and  mucopurulent  secretions  may  be  washed  out  of  these 
parts,  and  their  absorption  thereby  largely  prevented.  The  danger  of  forc- 
ing fluid  through  the  Eustachian  tube  into  the  ear  and  thereby  causing  an 
internal  ear  complication  is  slight  as  compared  with  the  danger  of  infection 
from  the  purulent  material  if  it  is  not  dislodged  and  the  inflammation 
modified  or  controlled  by  irrigation.  Atomizers  may  be  used  for  the  same 
purpose,  but  they  are  much  less  effective  than  the  nasal  douche  in  the 
cleansing  of  the  nasopharynx. 

Stomach  Washing  (Lavage). — This  therapeutic  measure,  introduced  by 
Epstein,  is  of  value  in  selected  cases.  Its  value  and  range  of  application, 
however,  are  not  so  great  in  the  child  as  they  are  in  the  adult.  The  older 
child  is  commonly  so  terrified  by  this  measure  that  the  resistance  which  it 
offers  makes  lavage  of  doubtful  efficacy  in  all  except  the  most  urgent  con- 
ditions, such  as  poisoning,  or  in  conditions  of  unconsciousness,  where  even 
in  the  older  child  the  tube  may  be  introduced  without  resistance.  In  young 
infants,  however,  the  ease  with  which  this  procedure  is  carried  out  gives  it 
a  much  wider  range  of  application.  Its  chief  indication  is  for  the  relief  of 
gastric  irritability  and  for  removing  poisons  from  the  stomach.  It  is  ur- 
gently indicated  in  all  cases  of  poisoning  at  any  age  and  is  of  value  for 
the  relief  of  persistent  vomiting  associated  with  gastritis,  chronic  gastric 
indigestion,  and  pyloric  spasm.  This  method,  even  in  these  cases,  however, 
should  not  be  abused.  If  the  stomach  is  once  thoroughly  washed  out  and 
allowed  to  rest  for  four  or  five  hours,  water,  with  perhaps  the  addition  of 
a  little  lime  water,  may  be  given  for  a  number  of  hours  until  the  gastric 
irritability  has  subsided,  and  then  properly  selected  foods  will  be  retained 
if  the  case  be  one  of  simple  gastric  irritability.  If  the  vomiting  persists 
after  this  careful  procedure  the  case  is  probably  one  in  which  repeated 
stomach  washings  will  be  of  little  or  no  value. 

The  apparatus  used  consists  of  a  funnel  attached  by  means  of  soft  rubber 
tubing  to  a  No.  12  American  catheter.  A  small  piece  of  glass  tubing  is 
used  to  connect  the  rubber  tubing  with  the  catheter,  so  that  the  flow  of 
fluids  to  and  from  the  stomach  may  be  observed.  The  child  is  to  be  wrapped 
in  a  sheet  or  blanket  inclosing  its  arms  and  legs  so  that  it  may  be  firmly 
held  by  an  attendant.  It  may  be  placed  on  a  table,  flat  on  its  back,  or  may 
be  held  in  a  sitting  posture,  with  its  head  upright  against  the  body  of  the 
nurse.  The  finger  of  the  left  hand  is  now  introduced  into  the  mouth,  de- 
pressing the  tongue,  and  with  the  right  hand  the  catheter  is  introduced 
into  the  esophagus  and  directed  downward  into  the  stomach.  In  the  young 
infant  there  is  no  difficulty  whatever  in  this  procedure.  The  catheter  on 
gentle  pressure  finds  its  way,  without  accident,  into  the  stomach.  The  in- 
fant's mouth  may  be  held  open  by  holding  the  index  finger  between  its 


50        THERAPEUTICS    OF   INFAISjCY   AND    CHILDHOOD 


gums,  and  if  it  has  both  upper  and  lower  incisors  the  catheter  is  to  be 
pushed  to  one  or  the  other  side,  so  that  the  teeth  will  not  impinge  upon  it. 
When  six  or  seven  inches  of  the  catheter  have  been  introduced,  the  funnel 
should  be  depressed  for  the  purpose  of  siphoning  out  the  contents  of  the 
stomach.  A  common  salt  solution  (teaspoonful  to  the  quart)  or  the  same 
strength  of  bicarbonate  of  soda  solution  at  a  temperature  of  100°  F.  may 
now  be  poured  into  the  funnel,  which  is  elevated  to  a  sufficient  height  to 
allow  the  fluid  to  flow  slowly  into  the  child's  stomach.     When  the  stomach 

is  full,  as  indicated  by  the 
contents  of  the  funnel, 
both  the  funnel  and  tube 
should  be  depressed  to  a 
point  which  will  allow  the 
contents  of  the  stomach  to 
be  siphoned  off.  This 
process  is  to  be  repeated 
a  number  of  times,  until 
the  water  which  is  siphoned 
from  the  stomach  is  clear, 
indicating  that  the  stom- 
ach has  been  cleansed.  If 
after  introducing  the  tube 
into  the  stomach  no  fluid 
is  returned,  it  is  possible 
that  the  catheter  has  been 
obstructed  by  mucus  or 
food.  Under  such  condi- 
tions it  is  necessary  to  re- 
move, cleanse,  and  reinsert 
the  catheter.  In  with- 
drawing the  catheter  from 
the  stomach  it  is  impor- 
tant to  make  firm  pres- 
sure on  the  soft  tubing,  so 
that  the  fluid  contained  in 
the  catheter  may  not  es- 
cape into  the  throat  and  larynx  during  the  process  of  withdrawal.  This  is 
especially  important  in  those  cases  where  it  is  necessary  to  insert  the  cathe- 
ter through  the  nose  into  the  stomach  rather  than  through  the  mouth. 

Gavage. — Gavage,  or  the  introduction  of  food  into  the  stomach  through 
a  tube,  should  be  preceded  by  preliminary  stomach  washing.  After  the 
stomach  has  been  thoroughly  emptied,  certain  foods,  such  as  breast-milk, 
peptonized  milk,  albumin  water,  meat  juice,  and  certain  prepared  meat 
preparations,  may  be  introduced  into  and  left  in  the  stomach.  Kerley  has 
shown  that  food  may  sometimes  be  retained,  when  introduced  in  this  Avay, 
in  cases  of  persistent  vomiting  in  infancy.     Gavage  may  also  be  indicated 


Fig.  10. — Stomach-Washing. 


OTHER   METHODS   OF    TREATMENT  51 

in  tlie  feeding  of  premature  infants  and  in  severe  diseases,  such  as  pneu- 
monia, typhoid  fever,  and  meningitis,  where  the  condition  of  the  patient 
makes  it  either  impossible  to  administer  food  by  the  mouth,  or  where  the 
irritability  of  the  stomach  is  such  that  the  food  is  not  retained  when  given 
in  this  way. 

Eectal  Enemata. — The  value  of  enteroclysis,  or  the  introduction  of  nor- 
mal salt  solution  into  the  colon  to  supply  fluids  to  the  tissues  and  organs 
in  conditions  of  collapse,  starvation,  uncontrollable  vomiting,  profuse  hem- 
orrhage and  nephritis  has  been  referred  to  under  the  heading  Hypodermo- 
clysis.  Ordinary  enemata,  however,  are  indicated  for  very  different  con- 
ditions. They  have  great  curative  value  in  acute  and  chronic  enterocolitis 
and  especially  in  those  cases  in  which  there  is  a  marked  tenesmus,  with 
mucous  and  bloody  discharges.  The  flushing  of  the  colon  in  these  cases 
with  a  normal  salt  solution  washes  away  the  fecal  matter  and  mucus, 
exercises  a  local  curative  influence  on  the  mucous  membrane,  diminishes 
the  intestinal  toxemia,  and  reduces  the  fever  and  nervous  symptoms  from 
which  these  patients  suffer. 

In  the  giving  of  rectal  enemata  for  washing  out  the  colon,  a  small 
rubber  catheter  should  be  inserted  six  or  eight  inches  into  the  bowel;  it  is 
not  necessary  to  introduce  the  tube  higher.  Through  this  catheter,  which 
is  attached  to  an  ordinary  fountain  syringe,  salt  solution,  one  teaspoonful 
to  a  quart,  is  allowed  to  flow.  The  quantity  of  fluid  introduced  will  de- 
pend upon  the  individual  case,  and  varies,  in  the  infant  and  young  child, 
from  a  pint  to  a  quart.  When  the  catheter  is  removed  pressure  is  to  be 
made  upon  the  buttocks  and  the  child  kept  quietly  in  bed  so  that  the  fluid 
may  be  retained  for  a  time,  in  order  that  it  may  more  thoroughly  dissolve 
the  mucus  and  fecal  matter  and  thereby  more  effectually  cleanse  the  bowel. 
In  giving  the  injection  the  child's  position  should  be  either  on  the  back 
or  left  side,  with  the  buttocks  slightly  higher  than  the  body,  and  the  fluid 
should  be  allowed  to  flow  slowly  into  the  bowel. 

Rectal  injections  of  salt  water  are  also  of  great  value  for  the  relief  of 
constipation,  and  when  given  for  this  purpose  the  smallest  possible  quan- 
tity of  water  which  will  produce  the  desired  result  should  be  used.  This 
procedure  produces  less  irritation  than  any  of  the  local  measures  we  have 
for  the  relief  of  constipation.  It  is  especially  valuable  during  the  first 
year  of  life ;  in  many  cases  it  may  be  necessary  to  continue  the  use  of  small 
salt  water  injections  over  a  period  of  many  months,  until  the  infant  is  old 
enougli  to  have  its  constipation  corrected  by  diet  or  other  means. 

Kerley  has  emphasized  the  great  value  of  injections  of  small  quantities 
of  olive  oil  for  the  relief  of  constipation.  This  method  is  of  special  value 
in  children  over  one  year  of  age.  From  one  to  three  ounces  of  olive  oil 
should  be  injected  into  the  colon  before  the  child  goes  to  bed,  and  should 
be  allowed  to  remain  there,  if  possible,  over  night,  or  until  the  oil  excites 
sufficient  peristalsis  to  produce  an  evacuation  of  the  bowels.  This  is  with- 
out dou])t  a  remedy  of  great  value  in  children  over  one  year  of  age. 

Rectal  Feeding. — Rectal  feeding  is  nothing  like  so  successful  or  so  fre- 


53        THERAPEUTICS    OF   INFANCY   AND    CHILDHOOD 

quently  indicated  in  the  child  as  it  is  in  the  adult.  Nutrient  enemata, 
however,  may  be  of  value  in  uncontrollable  vomiting,  in  acute  gastritis 
produced  by  the  swallowing  of  caustic  chemicals,  and  in  other  conditions 
where  it  is  impossible  for  a  prolonged  period  to  feed  the  child  by  the  mouth. 
The  food  materials  used  for  this  purpose  are  soluble  peptone  preparations, 
egg  albumin,  peptonized  milk,  and  dextrinized  gruels.  It  may  also  very 
rarely  be  necessary  to  introduce  into  the  colon  certain  stimulants,  such  as 
whiskey,  brandy,  digitalis,  strophanthus,  and  strychnin.  When  this  be- 
comes necessary  these  stimulants  should  be  well  diluted  with  normal  salt 
solution  or  dextrinized  gruels.  Rectal  stimulation,  however,  in  infancy 
and  childhood  is  for  the  most  part  uncertain  and  unsatisfactory. 

Rectal  Suppositories.' — Rectal  suppositories  are  very  largely  used  and 
their  use  very  greatly  abused  in  the  treatment  of  constipation  in  infancy 
and  childhood.  Soap  and  glycerin  suppositories,- which  are  in  such  general 
use,  are  very  effective  for  unloading  the  lower  bowel,  but  their  habitual  use 
is  productive  of  much  harm.  These  suppositories  in  time  produce  more 
or  less  rectal  irritation  and  predispose  to  hemorrhoids  and  fissures  of  the 
anus.  The  rectal  irritation  produced  by  these  suppositories  makes  the 
sphincter  more  irritable  and  by  causing  its  contraction  aggravates  the  con- 
stipation. Suppositories  are  here  mentioned,  therefore,  chiefly  for  the 
purpose  of  condemning  their  habitual  use.  An  occasional  glycerin  sup- 
pository may  be  justifiable.  Gluten  suppositories  are  much  less  effective 
and  are  much  less  irritating  to  the  rectum,  and  may  be  used  at  infrequent 
intervals  with  comparatively  little  danger  of  producing  disease  of  the 
rectum. 

Suppositories  are  very  commonly  used  in  the  adult  as  a  vehicle  for 
giving  opium,  belladonna,  and  other  remedies,  but  they  are  very  rarely  .used 
for  this  purpose  in  the  child.  Collargum,  however,  may  be  very  advan- 
tageously given  in  this  way  to  older  children  in  the  treatment  of  general 
septic  conditions. 

Rest  and  Muscular  Exercise. — Rest  in  bed  and  muscular  exercise  are 
therapeutic  measures  of  the  greatest  importance  in  the  cure  of  disease. 
In  order,  however,  that  the  best  results  may  be  obtained  from  these  meas- 
ures they  must  be  prescribed  with  a  precision  that  requires  more  skill  and 
acumen  on  the  part  of  the  physician  than  are  required  for  the  giving  of 
drugs,  or  for  the  proper  use  of  any  other  therapeutic  measure.  It  should 
further  be  remembered  that  to  obtain  the  best  results  the  fresh  air  treat- 
ment must  be  combined  with  these  agencies  in  the  treatment  of  disease. 

Rest  Cure. — Under  this  heading  may  be  included  rest  in  bed,  which  is 
absolutely  necessary  in  the  treatment  of  pneumonia,  scarlet  fever,  typhoid 
fever,  and  all  the  acute  infectious  diseases.  In  appendicitis  and  acute  in- 
flammatory diseases  involving  the  peritoneum,  the  rest  in  bed  must  be 
prolonged  until  convalescence  is  thoroughly  established.  In  acute  nephri- 
tis the  patient  must  be  confined  to  bed  until  the  urine  findings  are  normal. 
In  tuberculosis,  associated  with  fever,  the  patient  should  rest  in  a  reclining 
position,  or  in  a  comfortable  chair  in  the  open  air,  until  the  active  tuber- 


OTHER    METHODS    OF    TREATMENT  53 

culous  process  is  under  control.  In  acute  diseases  of  the  heart,  such  as 
myocarditis,  endocarditis,  and  pericarditis,  prolonged  rest  in  bed  is  the 
most  valuable  therapeutic  agent  we  have.  The  temporary  recovery  as  well 
as  the  future  welfare  of  these  cardiac  cases  depends  to  a  large  degree  upon 
the  skill  with  which  the  physician  prescribes  the  period  of  rest  and  the 
gradual  return  to  light  exercise.  In  many  of  the  functional  nervous  dis- 
orders of  childhood  rest  in  bed  under  quiet  surroundings  and  under  the 
careful  direction  of  a  tactful  nurse  is  of  great  value.  Northrup  has  em- 
phasized the  value  of  this  method  of  treatment  in  neurotic  infants  suffer- 
ing from  indigestion,  sleeplessness,  and  other  nervous  symptoms. 

Massage. — Massage  is  a  valuable  therapeutic  agent.  It  gives  tone  and 
strength  to  muscles  which  have  weakened  under  injury  or  disease;  it  im- 
proves the  circulation  in  superficial  muscles  and  other  tissues;  it  stimulates 
the  functional  activity  of  certain  internal  organs,  such  as  the  liver  and 
intestines;  it  acts  as  a  general  tonic,  stimulating  normal  processes  of 
metabolism ;  it  has  a  sedative  effect  on  the  nervous  system ;  and  it  promotes 
the  elimination  of  toxins,  especially  autotoxins. 

General  massage  is  of  special  value  to  children  when  more  active  forms 
of  exercise  are  contraindicated  or  when  they  are  suffering  from  deformities 
which  cannot  be  reached  by  active  exercise.  It  may  be  indicated  in  recur- 
rent vomiting  (interval  treatment),  general  malnutritions,  chronic  tuber- 
culosis, chronic  anemia,  and  in  all  conditions  in  which  the  muscles  of  the 
child  are  poorly  developed.  It  is  indispensable  for  the  proper  treatment  of 
spastic  and  flaccid  paralyses  associated  with  cerebral  and  spinal  palsies.  In 
these  conditions  massage  is  to  be  associated  with  proper  orthopedic  treat- 
ment, not  only  for  developing  the  muscles,  but  for  correcting  the  deformi- 
ties. In  chronic  constipation  massage  is  of  special  value.  In  this  condi- 
tion deep  massage  beginning  at  the  cecum  is  to  follow  the  line  of  the  colon 
to  the  sigmoid  flexure ;  the  so-called  cannon-ball  massage,  which  consists  in 
rolling  a  covered  iron  ball  weighing  three  or  four  pounds  around  the  cir- 
cumference of  the  abdomen  in  the  direction  of  the  colon,  is  a  valuable  expe- 
dient in  some  cases. 

Passive  and  Resisted  Movements. — Passive  and  resisted  movements 
are  of  value  in  the  correction  of  deformities  and  the  development  of  muscles 
weakened  or  paralyzed  by  injury  or  disease  of  the  nervous  system.  The 
contractures  which  occur  in  cerebral  palsies  should  receive  this  form  of 
treatment. 

Gymnastic  Exercises. — Gymnastic  exercises,  when  skilfully  directed 
and  carefully  carried  out,  are  of  very  gi'eat  value  in  correcting  spinal  curva- 
tures and  other  deformities  not  due  to  organic  disease  of  the  bones  or 
nervous  system.  Under  a  skilful  physical  director  these  exercises  may  give 
symmetry  of  development  to  the  body. 

Breathing  Exercises. — Breathing  exercises,  when  properly  done  in 
the  open  air,  increase  the  respiratory  capacity,  carry  more  oxygen  into  the 
lungs  and  blood,  promote  the  elimination  of  carbonic  acid,  and  thereby  act 
as  a  general  blood  tonic,  improving  nutritional  processes. 


54        THEEAPEUTICS    OF   INFANCY   AND    CHILDHOOD 

It  is  of  importance  that  every  child  should  be  taught  how  to  breathe  so 
as  to  develop  his  full  lung  capacity.  This  can  only  be  done  by  combining 
with  deep  inspiration  and  slow  expiration  certain  body  and  chest  move- 
ments, which  will  bring  into  play  not  only  the  diaphragm  and  intercostal 
muscles,  but  all  the  accessory  muscles  of  inspiration.  If  the  habit  of  proper 
breathing  is  acquired  during  childhood  it  commonly  becomes  a  habit  which 
lasts  through  life. 

Breathing  exercises  are  of  value  in  undersized,  malnourished  children 
with  poor  lung  capacity.  They  are  especially  indicated  in  chronic  anemia 
and  chronic  tuberculosis,  as  well  as  in  children  who,  by  reason  of  enlarged 
tonsils  and  adenoids,  have  poorly  developed  chests. 

Outdoor  Play. — The  ordinary  outdoor  games,  such  as  ball,  tennis, 
skating,  running,  jumping,  etc.,  are  vastly  superior  to  the  forms  of  exer- 
cise above  noted  for  the  development  of  the  normal  child.  Outdoor  games 
are  also  of  value  in  promoting  the  physical  and  incidentally  the  mental 
development  of  children  who  from  heredity,  environment,  or  chronic  illness 
are  below  the  normal  in  physical  development.  In  many  instances,  how- 
ever, outdoor  sports  when  directed  only  by  the  child's  instincts  and  desires 
are  too  strenuous  or  otherwise  unsuited  to  bring  about  the  best  results  in 
development  in  an  individual  case.  In  such  instances  the  physician  may 
prescribe  modified  outdoor  sports  under  careful  supervision,  and  that  may 
be  combined  with  gymnastic  exercises,  breathing  exercises,  passive  and  re- 
sistant exercises  or  massage,  according  to  the  demands  of  the  individual 
case.  Exercises,  manipulations,  and  movements  to  accomplish  definite  and 
specific  results  must  be  carried  out  under  the  direction  of  an  instructor, 
and  massage,  passive  and  resisted  movements  must  be  intelligently  done  by 
one  who  understands  the  results  which  the  physician  seeks  to  obtain  in  the 
individual  case. 

Psychotherapy. — In  the  treatment  of  neurotic  disorders  in  children,  as 
well  as  in  the  adult,  psychotherapy  is  a  valuable  therapeutic  agent.  The 
young  child  suffering  physical  pain,  or  with  wounded  feelings,  crying  bit- 
terly, rushes  into  the  arms  of  his  mother,  she  presses  him  to  her  breast, 
kisses  away  his  tears,  and  by  a  kind  and  tactful  word  makes  him  forget 
his  woes,  directs  his  plastic  mind  into  other  channels  of  thought  and  sends 
him  away  laughing  and  happy.  This  is  an  everyday  example  of  the  power- 
ful influence  which  suggestion  may  exercise  over  the  emotional,  imaginative, 
and  imitative  mind  of  the  young  child.  By  word  pictures  alone  the  im- 
aginative mind  of  the  child  may  be  made  to  see  terrifying  objects  which 
may  cause  a  sleepless  night.  On  the  other  hand,  the  sleepless,  nervous 
child,  whose  mind  has  been  excited  by  an  overwrought  imagination  or  by 
undue  nervous  strain  before  going  to  bed,  may  be  quieted  and  ofttimes  put 
to  sleep  by  reassuring  words  from  a  forceful,  tactful,  and  sympathetic 
mother,  who  knows  how  to  use  the  control  which  the  unlimited  confidence 
of  her  child  has  given  her  over  its  emotional  nature. 

Nervous  habits,  such  as  stammering,  habit-spasm,  masturbation,  nail- 
biting  and  dirt-eating,  may  be  contracted  by  association  with  other  children 


OTHER    METHODS    OF    TREATMENT  55 

having  these  habits.  The  imitative  nature  of  the  child  makes  it  possi- 
ble to  influence  its  immature  nervous  system  for  good  or  evil  by 
favorable  or  unfavorable  surroundings.  In  the  treatment  of  the  above- 
named  nervous  habits  it  is  important,  therefore,  that  the  patient  should 
not  be  associated  with  nervous  children  or  be  under  the  care  of  a  nervous, 
emotional  nurse.  It  may  be  necessary  to  tactfully  disregard  or  forcibly 
control  certain  nervous  habits,  or,  again,  it  may  be  wise  to  ingenuously  dis- 
claim the  existence  of  nervous  symptoms.  In  this  manner  the  child  may 
be  surrounded  by  an  atmosphere  which  will  cause  it  to  be  interested  in  out- 
side things  and  less  intent  upon  its  own  nervous  condition.  At  times  it 
may  be  necessary  to  separate  a  nervous  child  from  its  surroundings  and 
place  it  under  the  exclusive  care  of  a  kind,  firm,  tactful  nurse.  The  child 
very  quickly  realizes  that  it  cannot  enlist  the  sympathy  of  the  nurse,  as  it 
did  its  mother's,  by  emotional  outbursts.  Under  such  conditions  the  kindly 
indifference,  the  tactful  firmness,  and  the  gentle  attentiveness  of  the  nurse 
may  exercise  a  most  helpful  influence  in  the  cure  of  hysterical  and  kindred 
neurotic  disorders  of  childhood.  It  is  difficult  to  formulate  rules  to  guide 
the  physician  in  the  use  of  psychotherapy  as  a  therapeutic  measure.  It  is 
important  to  remember  that  children  are  emotional,  imaginative  and  imi- 
tative, and  that  their  immature  minds  are  very  receptive  and  easily  influ- 
enced by  suggestion  from  those  in  whom  they  have  confidence.  The  physi- 
cian who  has  a  good  working  knowledge  of  child  nature,  the  skill  to  apply 
this  knowledge  in  controlling  the  child's  emotions,  and  the  tact  to  accom- 
plish this  through  the  co-operation  of  the  mother  will  find  many  oppor- 
tunities for  using  psychotherapy  as  a  therapeutic  measure,  not  only  in  the 
ordinary  neuroses  of  childhood,  but  in  many  other  diseases  in  which  nervous 
symptoms  are  prominent. 

Vaccine  Therapy. — In  1903  A.  E.  Wright  demonstrated  the  presence  of 
certain  substances  in  blood  serum,  which  by  their  action  so  disabled  bacteria 
that  phagoc}i;ic  cells  could  more  easily  take  them  up  and  destroy  them; 
these  substances  he  called  opsonins.  Previous  to  this  discovery  it  was 
known  that  certain  other  bodies  in  the  blood  had  the  power  of  destroying  or 
limiting  the  action  of  bacteria:  "the  agglutinins"  conglomerated  bacteria; 
"the  bacteriolysins"  and  'Tsacteriocidal  substances'*  destroyed  them.  All  of 
these,  including  opsonins,  are  called  antibodies,  because  of  their  antagon- 
ism to  bacteria  and  other  foreign  cells  that  happen  to  find  an  entrance  into 
the  body  media. 

Wright  believes  that  nature  by  the  development  of  a  specific  opsonin  for 
each  bacterium  makes  it  possible  for  the  phagocytes  to  limit  the  course  and 
modify  the  severity  of  both  local  and  general  bacterial  infections.  He  also 
believes  that  both  natural  and  acquired  immunity  against  bacterial  infec- 
tion depends  much  more  upon  the  opsonic  content  of  the  blood  than  upon 
any  of  the  other  antibodies.  These  views  naturally  led  Wright  to  the  de- 
velopment of  a  method  which  had  for  its  purpose  the  cure  of  bacterial  dis- 
eases by  artificially  increasing  in  the  blood  serum  of  the  patient  the  particu- 
lar opsonin  which  assisted  in  the  phagocytosis  of  the  specific  microorganism 
causing  the  infection. 


56         THERAPEUTICS    OF   INFANCY   AND    CHILDHOOD 

Opsonic  Index. — The  opsonic  power,  or  opsonic  content  of  an  individ- 
ual patient's  blood  serum,  when  divided  by  the  opsonic  power  or  opsonic 
content  of  the  blood  serum  of  a  normal  individual,  will  give  the  opsonic 
index  of  the  patient's  blood  serum.  The  opsonic  index  thus  obtained  may 
in  skilful  hands,  as  Wright  has  demonstrated,  be  of  value  in  an  individual 
case  in  determining  the  necessity  for  vaccine  treatment,  as  Avell  as  the  dose 
of  the  vaccine  to  be  administered,  and  subsequently  the  influence  which  the 
dose  of  vaccine  has  had  in  increasing  the  opsonins  in  the  blood. 

Accumulated  experience  with  the  vaccine  treatment  has  demonstrated 
that  successful  vaccine  therapy  may  be  carried  on  without  the  use  of  the 
opsonic  index,  and  this  has  brought  vaccine  therapy  within  the  scope  of  the 
general  practitioner. 

Without  Opsonic  Index. — In  giving  bacterial  vaccines  with  no  knowl- 
edge of  the  individual  patient's  opsonic  index  it  is  advisable  to  begin  with 
a  small  dose.  The  size  of  the  subsequent  doses  as  well  as  the  length  of 
the  interval  between  the  treatments  may  then  be  determined  by  the  clinical 
reaction.  The  "clinical  reaction"  is  manifested  by  a  slight  rise  in  tempera- 
ture, a  feeling  of  malaise,  and  by  a  slight  exaggeration  of  existing  symp- 
toms. After  twenty-four  hours  this  is  followed  by  a  fall  in  temperature 
and  general  improvement  in  all  the  symptoms. 

As  a  guide  to  the  giving  of  bacterial  vaccines  without  the  use  of  the 
opsonic  index,  the  following  rules  may  be  observed: 

1.  Begin  with,  a  small  dose. 

2.  If  no  "clinical  reaction"  whatever  occurs,  and  no  improvement  in 
the  patient's  condition  takes  place  within  three  days,  a  second  and  larger 
dose  may  be  given.  This  rule  of  action  may  be  followed  until  a  "clinical 
reaction"  does  occur,  or  until  the  patient  commences  to  improve  under  the 
treatment.  If  the  patient  is  improving  under  a  certain  dose  of  vaccine, 
even  though  no  "clinical  reaction"  occur,  the  same  dose  should  be  con- 
tinued at  a  five  to  seven-day  interval.  Wright  does  not  believe  it  advisable 
to  elicit  the  "clinical  reaction"  as  an  indication  that  the  size  of  the  dose 
is  sufficient.  Improvement  in  the  symptom  group  is  a  more  reliable  in- 
dication. 

3.  If  the  "clinical  reaction"  follows  the  giving  of  a  dose  of  vaccine 
and  this  is  followed  by  improvement  in  the  patient's  symptoms,  a  second 
and  smaller  dose  should  be  repeated  in  six  or  seven  days,  and  this  rule  of 
action  is  to  be  continued  as  long  as  vaccine  therapy  is  indicated. 

4.  If  a  "clinical  reaction"  is  not  followed  by  improvement  in  the 
patient's  condition,  vaccine  therapy  is  not  indicated  and  may  do  harm  in 
that  particular  case. 

Bacterial  Vaccines. — Bacterial  vaccines  consist  of  sterile  mixtures  of 
dead  bacteria  in  salt  solution.  Each  c.  c.  of  these  vaccines  contains  a 
definite  number  of  dead  bacteria.  The  dose  of  the  vaccine  is  regulated  by 
the  number  of  dead  bacteria  one  desires  to  give  in  an  individual  case.  There 
is  as  yet  no  way  by  which  the  potency  of  the  dose  may  be  accurately  stand- 
ardized.    One  does  inject  a  definite  number  of  killed  bacteria,  but  the 


OTHER    METHODS    OF    TREATMENT  57 

potency  of  this  dose  depends  not  alone  upon  the  number  of  bacteria  in- 
jected, but  also  upon  the  virulency  of  the  particular  bacterial  culture  from 
which  this  vaccine  was  made.  This  inaccuracy  in  dosage,  together  with 
our  lack  of  knowledge  as  to  the  manner  in  which  an  individual  patient 
will  react  to  different  vaccines,  makes  the  proper  initial  dose  in  every  in- 
stance more  or  less  problematical;  for  these  reasons  it  is  desirable  to  begin 
with  small  doses,  which  experience  has  taught  are  safe. 

The  best  results  from  vaccine  treatment  are  obtained  by  the  use  of 
autogenous  vaccines,  that  is  to  say,  vaccines  which  are  prepared  from  a 
culture  of  the  individual  organism  causing  the  disease.  The  difficulty  in 
the  technique,  however,  makes  it  rarely  possible  for  the  general  practi- 
tioner to  use  autogenous  vaccines;  this  is  possible  only  when  he  has  at  his 
disposal  a  well-equipped  laboratory  and  the  assistance  of  a  competent  bac- 
teriologist. This  difficulty  has  brought  into  more  or  less  general  use  the 
stock  vaccines  now  on  the  market,  which  can  in  many  instances  be  relied 
upon  to  produce  satisfactory  therapeutic  results  if  the  practitioner  has  the 
facilities  at  hand  for  making  an  accurate  bacteriological  diagnosis.  For 
example,  if  it  is  definitely  determined  that  a  given  infection  is  due  to  a 
certain  staphylococcus,  or  that  there  is  a  double  infection  in  which  both 
the  staphylococcus  and  gonococcus  play  a  part,  then  the  physician  by  the 
use  of  the  respective  stock  vaccines  for  combating  infections  caused  by 
these  organisms  may  hope  to  obtain  satisfactory  results. 

The  safe  initial  dose  of  the  staphylococcus  vaccine,  during  the  first  year 
of  life,  is  about  5,000,000  dead  staphylococci ;  during  the  second  year  of 
life  about  10,000,000;  during  the  third  year  about  30,000,000;  during  the 
fourth  year  about  30,000,000 ;  increasing  5,000,000  each  year  thereafter  up 
to  the  tenth  year  of  life,  when  it  is  about  60,000,000.  The  safe  initial  dose 
of  the  gonococcus  vaccine  is  about  one-tenth  that  of  the  staphylococcus  vac- 
cine above  given,  and  that  of  streptococcus  and  pneumococcus  vaccines 
about  one-fifth. 

Therapeutic  Indications. — Vaccines  are  indicated  in  localized  rather 
than  in  general  infections,  and  in  subacute  and  chronic  rather  than  in 
acute  infections.  It  would  appear  from  the  present  literature  on  this  sub- 
ject that  vaccines  are  of  value  in  acute  general  infections  only  when  the 
infection  is  mild  or  when  the  vaccine  is  given  very  early  in  the  disease. 
In  a  severe,  acute,  general  infection  there  is  danger  that  the  vaccine  may 
aggravate  the  disease  and  not  be  followed  by  a  favorable  reaction.  In  these 
cases  the  tissues  under  the  stimulation  of  the  general  bacterial  invasion 
have  already  furnished  the  "high  tide"  of  opsonins  for  the  individual  case 
and  cannot  further  be  stimulated  to  produce  an  increased  quantity  of  these 
curative  agents.  The  definite  field  of  vaccine  therapy  has  not  as  yet  been 
determined,  but  there  is  no  doubt  that  it  exercises  a  curative  influence  in 
a  group  of  cases  which  do  not  yield  readily  to  other  methods  of  treatment. 

Localized  staphylococcic  infections,  especially  those  due  to  the  staphy- 
lococcus pyogenes  aureus,  such  as  occur  in  furunculosis,  pustular  acne, 
sycosis,  cystitis,  carbuncle,  and  osteomyelitis,  may  be  favorably  influenced. 


58        THERAPEUTICS    OF   INFANCY   AND    CHILDHOOD 

and  recovery  accelerated  by  the  use  of  the  staphylococcus  vaccines.  While 
the  above  named  conditions  are  very  commonly  due  to  staphylococcic  in- 
fection, it  is  advisable  to  determine  this  fact  by  bacteriologic  examination 
before  using  the  vaccine.  Especially  good  results  have  been  obtained  by 
this  method  in  the  treatment  of  clironic  furunculosis.  In  the  treatment  of 
pustular  acne  with  infiltration  a  combination  vaccine  containing  both  dead 
staphylococci  and  dead  acne  bacilli  has  been  used  with  advantage. 

Koch's  tuberculin  has  been  successfully  used  as  a  vaccine  in  the  treat- 
ment of  tuberculosis,  but  it  is  of  little  value  in  the  treatment  of  this  disease 
during  the  first  year  of  life.  Localized  non- febrile  forms  of  chronic  tuber- 
culosis (not  meningeal),  in  children  over  two  or  three  years  of  age,  may 
be  greatly  benefited  by  this  treatment,  provided  it  is  carried  out  as  recom- 
mended by  Trudeau.  One  should  begin  with  very  minute  doses,  .001  mg., 
and  increase  very  gradually.  The  dose  should  be  graduated  so  as  to  pro- 
duce a  very  slight  clinical  reaction.  A  second  dose  should  not  be  given 
for  some  days  after  all  effects  of  the  previous  reaction  have  passed  away. 
This  treatment  should  be  continued  only  in  those  cases  that  continue  to 
improve.  It  should  not  be  hastened,  as  it  requires  many  months  to  get 
results.  The  tuberculin  treatment  may  hasten  the  cure  of  cases  which  by 
reason  of  outdoor  life  and  proper  food  have  begun  to  improve,  and  have 
thereby  indicated  that  the  opsonic  content  of  their  blood  may  be  increased 
by  vaccine  treatment. 

Gonococcu^  vaccine  is  of  little  value  in  the  treatment  of  acute  gonor- 
rhea except  perhaps  in  the  gonococcic  vulvovaginitis  of  young  infants,  but 
in  chronic  cases,  both  in  children  and  adults,  the  published  reports  indicate 
that  it  may  shorten  the  course  of  this  disease.  The  most  important  field 
for  the  gonococcic  vaccine  is  found  in  the  complications  which  are  due  to 
the  action  of  this  organism  in  other  parts  of  the  body.  In  subacute  and 
chronic  gonorrheal  arthritis,  and  in  chronic  suppurative  processes  pro- 
duced by  gonococci  in  any  part  of  the  body,  the  proper  surgical  treatment 
of  these  conditons  will  much  more  readily  bring  about  a  cure  when  com- 
bined with  the  use  of  the  gonococcus  vaccine. 

Streptococcus  vaccine  is,  as  a  rule,  not  indicated  in  acute  general  strep- 
tococcic infections,  but  in  all  localized  streptococcic  infections,  especially  if 
they  be  subacute  or  chronic,  this  vaccine  may  be  of  value  in  facilitating  a 
cure.  Such  localized  streptococcic  infections  occur  most  commonly  in 
association  with,  or  as  sequels  of,  influenza,  epidemic  grippe,  tonsillitis, 
scarlet  fever,  tuberculosis  and  other  acute  infectious  diseases.  The  ordi- 
nary sites  of  localized  streptococcic  infection  are  lymphatic  glands,  the 
serous  cavities,  the  accessory  sinuses  of  the  nose  and  the  subcutaneous  tis- 
sues. In  properly  selected  cases  of  this  character  the  streptococcus  vaccine 
may  be  of  value.  In  the  treatment  of  streptococcic  infections  autogenous 
vaccines  are  much  to  be  preferred,  because  of  the  great  variety  of  strains 
of  this  organism. 

Pneumococcus  vaccine  is  of  little  or  no  value  in  the  treatment  of  gen- 
eral pneumococcic  infections  or  of  pneumococcic  pneumonia  during  the 


OTHER   METHODS    OF    TREATMENT  59 

acute  stage  of  the  disease.  It  may  be  of  value,  however,  in  chronic  forms 
of  pneumococcic  pneumonia  in  which  there  is  delayed  resolution;  in  sub- 
acute or  chronic  pneumococcic  empyema,  and  in  all  localized  pneumococcic 
infections,  such  as  may  occur  in  the  joints,  the  internal  ear,  accessory 
sinuses  of  the  nose  and  the  urinary  bladder. 

Typhoid  vaccine  has  been  successfully  used  as  a  prophylactic  measure 
against  typhoid  fever ;  its  value,  however,  in  the  treatment  of  the  disease 
itself  has  not  been  demonstrated.  The  vaccine  treatment  of  erysipelas, 
scarlet  fever  and  other  acute  infectious  diseases  has  not  as  yet  been  followed 
by  sufficient  success  to  demonstrate  its  value  during  the  acute  stages  of 
these  diseases. 

Coli  vaccine  is  a  valuable  remedy  in  infection  of  the  urinary  tract  due 
to  this  organism.  It  may  also  be  given  with  some  hope  of  success  in 
colicystitis  and  catarrhal  jaundice. 

Antiserums. — It  has  been  a  well-known  fact  for  many  years  that  most 
of  the  acute  infectious  diseases  are  self-limited,  run  a  more  or  less  definite 
course,  and  are  cured  by  the  development  in  the  body  of  the  animal  of 
antidotal  substances  acting  on  or  destroying  either  the  bacteria  or  their 
poisonous  products,  and  this  process  by  which  nature  effects  a  cure  of 
these  diseases  is  followed  by  a  period  of  permanent  or  temporary  immunity 
from  the  specific  bacterial  disease  from  which  the  animal  was  suffering. 
It  seemed  more  than  probable  that  if  antiserums  containing  these  antidotal 
substances  could  be  artificially  manufactured  by  immunizing  horses  or 
other  animals  by  the  injection  into  their  blood  or  other  tissues  of  certain 
bacteria  and  their  poisonous  products,  these  antiserums  would  act  specific- 
ally in  assisting  nature  in  terminating  or  curing  the  specific  infection 
caused  by  the  microorganism  which  was  used  to  produce  the.  antiserum. 
A  vast  amount  of  experimental  work  in  recent  years  has  been  directed  along 
these  lines  with  the  result  that  certain  antiserums  have  been  produced  which 
act  specifically  in  the  destruction  of  the  parasite  and  its  poisons  without 
producing  any  injurious  action  on  the  body  cells.  The  discovery  of  these 
antiserums  furnishes  the  most  notable  therapeutic  advance  in  the  history 
of  medicine. 

The  development  of  antiserums  for  the  cure  of  bacterial  diseases  is 
but  yet  in  its  infancy  and  many  of  the  problems  connected  with  their  manu- 
facture are  yet  to  be  solved.  Nevertheless,  the  achievements  in  this  field 
of  experimental  medicine  are  nothing  short  of  marvelous,  and  the  future 
promises  that  achievements  in  this  field  of  therapeutic  research  will  be 
even  more  brilliant  than  the  results  which  have  been  already  obtained.  At 
the  present  time  it  appears  that  there  are  at  least  two  distinct  classes  of 
antiserums. 

The  first  is  represented  by  the  diphtheria  and  tetanus  antitoxins.  In 
these  diseases  the  bacteria  acting  within  a  localized  area  of  infection 
excrete  soluble  poisons  which  are  distributed  through  the  circulating  media 
of  the  animal  to  all  parts  of  the  body,  producing  a  dangerous  and  fre- 
quently a  fatal  toxaemia.     The  antiserums  which  are  produced  for  the 


60        THERAPEUTICS    OF   INFANCY   AND   CHILDHOOD 

cure  of  these  diseases  are  essentially  antitoxins  which  combine  with  and 
neutralize  or  destroy  the  poisonous  effect  of  toxins,  thus  giving  nature 
an  opportunity  to  furnish  such  antibodies  as  are  necessary  to  effectually 
terminate  the  disease.  The  brilliant  results  which  have  followed  the  treat- 
ment of  diphtheria  by  antitoxin  are  fully  discussed  in  the  chapter  on 
Diphtheria. 

The  second  class  of  antiserums  is  represented  by  the  antimeningitis 
serum,  the  use  of  which  has  been  followed  by  such  brilliant  results  in  the 
treatment  of  meningococcus  meningitis.  This  serum  is  an  antiendotoxic 
serum  and  is  bacteriolytic  rather  than  antitoxic.  It  acts  primarily  by  de- 
stroying the  meningococcus  itself  and  secondarily  by  neutralizing  the 
action  of  the  toxins  set  free  by  the  destruction  of  this  microorganism.  The 
toxins  of  the  meningococcus,  unlike  those  of  the  diphtheria  bacillus,  re- 
main united  with  the  microorganisms  which  have  produced  them,  and  are 
not  therefore  thrown  into  the  body  media,  producing  a  general  toxemia. 
The  antimeningitis  serum  depends  for  its  bacteriolytic  action  upon  the 
opsonins  which  it  contains.  These  opsonins  prepare  the  meningococcus 
for  ingestion  and  destruction  by  the  leukocytes.  The  brilliant  results 
which  have  been  obtained  by  this  serum  are  given  in  detail  under  the 
treatment  of  Meningococcus  Meningitis. 

Twenty  years  ago  I  wrote  as  follows:^  "In  imitating  nature  experi- 
mental clinical  medicine  has  a  promising  field  here  opened  for  original 
work.  In  the  cure  and  prevention  of  disease  the  experimenter  may  use 
one  of  two  substances. 

1.  The  chemical  substances  produced  by  the  body  cells. 

2.  The  chemical  substances  produced  by  bacteria. 

Let  us  first  note  what  results  we  may  expect  from  the  use  of  chemical 
substances  produced  by  the  body  cells  in  curing  disease. 

(a)  By  injecting  these  substances  in  sufficient  quantity  into  the  body 
of  a  healthy  animal  we  would  expect  to  confer  complete  temporary  im- 
munity to  the  particular  bacterium  that  induced  their  formation.  But 
this  immunity  would  gradually  disappear  with  the  excretion  of  the  cause 
on  which  it  depended. 

(&)  By  injecting  these  substances  in  sufficient  quantities  into  the  body 
of  an  animal  sick  of  the  disease  we  would  expect  it  to  act  as  a  true  specific 
in  the  cure  of  the  disease. 

If,  therefore,  we  could  obtain  the  various  chemical  substances  with 
which  nature  cures  the  self-limited  diseases  and  with  which  she  confers 
a  temporary  immunity  against  them  we  would  have  the  means  not  only 
of  curing  but  of  preventing  these  diseases. 

Let  us  now  note  what  beneficial  results  may  be  expected  from  the  in- 
troduction of  the  products  of  bacteria.  Whatever  action  these  may  have 
must  depend  upon  their  power  of  exciting  the  body  cells  to  the  production 
of  substances  that  either  destroy  bacteria  or  neutralize  their  products  and 


'Mechanism  of  Immunity,"  Philadelphia  Medical  News,  April  23,  1892. 


OTHER  METHODS  OF  TREATMENT  61 

thus  terminate  the  disease  and  confer  immunity.  The  disease  is  here 
terminated  and  immunity  conferred  not  by  the  products  of  the  bacteria, 
but  by  the  products  of  the  cells  in  the  same  manner  as  when  the  cellular 
instead  of  the  bacterial  products  are  introduced.  "The  only  difference  is 
that  in  the  first  instance  the  cellular  products  are  formed  in  the  body  of 
one  animal  and  introduced  as  a  curative  or  prophylactic  agent  into  the 
body  of  another  animal  and  in  the  second  instance  the  cellular  products 
are  formed  in  the  body  of  the  animal  for  the  purpose  of  conferring  immun- 
ity,   *     *     *     or  terminating  a  self-limited  disease." 

In  the  paper  from  which  the  above  quotation  is  made  I  clearly  outlined 
the  possibilities  and  probabilities  of  the  vaccine  and  antiserum  treatment 
of  bacterial  diseases. 


SECTION   II 
THE  NEW-BORN 

CHAPTEE  V 

THE  CAEE  OF  PREMATUKE  INFANTS 

Physical  Peculiarities  of  the  Prematurely  Born. — Infants  born  prema- 
turely differ  from  full-term  infants  in  the  comparative  lack  of  functional 
development  of  many  of  their  most  important  organs.  By  reason  of  this 
lack  of  development  they  are  to  a  greater  or  less  degree,  depending  upon 
the  stage  of  prematurity,  unfitted  to  live  under  the  ordinary  conditions  of 
home  and  hospital  life.  The  most  important  and  the  most  serious  defect 
of  the  premature  infant  is  the  lack  of  development  of  its  nervous  system, 
and  especially  the  undeveloped  state  of  its  heat-regulating  apparatus.  Its 
thermogenic  centers  are  so  poorly  developed  that  it  is  unable  to  produce 
the  requisite  amount  of  heat  to  maintain  a  normal  body  temperature.  The 
body  temperature  of  the  unborn  infant  is  that  of  its  mother,  but  this  heat 
has  been  largely  furnished  by  the  surroundings  of  the  infant  and  is  not 
due  to  the  activity  of  its  own  heat-producing  centers.  At  birth  it  is  ushered 
into  a  room  temperature  between  70°  and  80°  F.,  and  its  body  tem- 
perature rapidly  falls  and  may  within  a  few  hours  be  as  low  as  85°  F. 
The  deficiency,  however,  of  its  heat-producing  centers,  which  makes  it  de- 
pendent upon  external  heat  for  the  maintenance  of  a  normal  body  tempera- 
ture, is  not  the  only  defect  in  its  heat-regulating  mechanism.  The  prime 
defect  in  the  nervous  system  of  the  premature  infant  is  the  almost  com- 
plete lack  of  development  of  its  inhibitory  functions,  and  this  lack  of  inhibi- 
tion is  especially  important  in  its  influence,  or  rather  lack  of  influence,  on 
the  heat-dissipating  mechanism.  This  part  of  the  heat-regulating  ap- 
paratus is  under  so  little  control  from  higher  nerve  centers  that  the  body 
heat  of  these  infants  is  very  rapidly  dissipated  when  they  are  transferred 
from  an  intrauterine  temperature  of  99°  F.  to  a  room  temperature  of 
70°  F.  The  thermoinhibitory  centers  of  these  infants  also  exert  but  little 
or  no  control  over  the  thermogenic  centers  and  as  a  result  of  this  malad- 
justment of  the  heat-regulating  mechanism  it  is  very  difficult  to  maintain 
a  normal  body  temperature  in  these  infants.  Artificial  heat  when  applied 
with  the  purpose  of  supplying  the  deficiency  in  body  heat  may  produce 

62 


PECULTAKITTES    OF    TTTE    PREMATURELY    BORX 


63 


dangerously  high  temperatures.  I  have  seen  the  rectal  temperature  of  a 
premature  infant  raised  to  109°  F.  by  a  careless  application  of  artificial 
heat,  and  in  the  same  infant  when  the  artificial  heat  was  removed  I  have 
seen  the  temperature  drop,  within  a  few  hours,  to  93°  F.  The  lack  of  de- 
velopment and  instability  of  the  heat-regulating  mechanism  of  the  prema- 
ture infant  predispose  these  infants  to  dangerously  high  and  low  tempera- 
tures from  insignificant  causes.    Artificial  heat,  which  is  necessary  to  main- 


TIME 

< 

< 

s* 
< 

i 

•i 
< 

i 

i 

z 

i 

2 

■" 

z 

i 

» 

i 

i 

z 

i 

I 

< 

I 

I 

< 

X 

* 

< 

Z 

< 

< 

i 

< 

i 

I    i 

s 

I 

s 

Z 

i 

z 

z 

z 

z 

z' 

108° 
107° 
106° 
105° 
104° 

kJ 
a 

?      103 

< 

c 

a      102 

kJ 

"      101 

h 
UJ 

i    100° 

u 
cc 

<        99° 
u. 

98 

97° 

96° 

95° 

94° 

93° 

,5 

5/ 

7 

\ 

V 

A- 

^ 

1 
1 

1 

A, 

\ 

/ 
/ 
/ 

/ 

f 

1 
1 
1 

1 
1 

\ 

j 

/ 

\ 

1 

^ 

1 

1 

1 

1 

t 
1 
1 
/ 

^ 

\ 

/ 

/ 

1 
1 
1 

1 

-S 

1 

/ 

t 

' 

\ 

I 

\ 

r 

1 

HI 

1 

1 
J 

1 

t 

\ 

V 

A 

i 

■V 

^ 

i 

1 
1 
1 

1 

\ 

V 

1 
1 

1 

1 
1 

3 

\ 

% 

1 

1 

i 

- 

n 

f 

z 

V 

1 

-5 

1 

1 

> 

V 

\ 

/ 

*.^ 

1 

1 

i 

I 

\ 

1 
1 

\ 

" 

I 

1 

' 

i 

\ 

1 

h 

I 

1 

1 

1 
1 

1 
1 

\ 

1 

\ 

,\ 

1 
1 

V 

f 

1 
1 

I. 

1 
1 
J 

V 

1 
>  1 
Ml 

/ 

. 

_ 

1 

If 

_ 

Fig.  11.- 


-Temperature  Curve  Showing  Influence  of  Artificial  Heat  on  Prema- 
ture Infant. 


tain  a  normal  body  temperature  in  these  infants,  should  be  applied  under 
the  most  careful  supervision. 

The  respiratory  centers  are  also  very  imperfectly  developed.  Many  of 
these  infants  are  more  or  less  asphyxiated  at  birth  and  in  all  of  them  the 
respiratory  movements  are  feeble  and  shallow.  The  respiratory  centers  in 
these  cases  do  not  respond  so  energetically  and  satisfactorily  to  external 
reflex  stimuli  as  they  do  in  the  full  term  infant. 

The  higher  nerve  centers  are  also  imperfectly  developed,  so  that  these 
infants  are  somnolent,  quiet  and  motionless  a  great  portion  of  the  time; 
6 


64  THE   CARE    OF   PREMATURE    INFANTS 

when  aroused  from  their  stupid  condition  they  whine  faintly,  instead  of 
uttering  the  lusty  cry  of  the  normal  infant. 

The  reflex  centers  in  the  spinal  cord,  as  well  as  those  of  the  brain  and 
medulla,  are  comparatively  undeveloped.  As  a  result  of  this  there  are  com- 
parative lack  of  muscular  movement  in  the  arms  and  legs,  deficient  tone 
in  the  muscles  of  the  extremities,  constipation  or  insufficient  evacuation  of 
the  bowels. 

The  second  most  important  defect  in  development  is  to  be  found  in  the 
digestive  tract.  The  digestive  organs  of  premature  infants  are,  as  com- 
pared with  those  of  the  normal  child,  to  a  greater  or  less  degree  physiologi- 
cally incompetent.  The  degree  of  this  physiological  incompetency  will 
depend  upon  the  stage  of  prematurity.  Infants  born  between  the  sixth  and 
seventh  month  may  manifest  little  inclination  to  suck;  this  reflex  function 
is  but  feebly  developed,  and  swallowing  may  be  accomplished  with  difficulty. 
In  infants  born  nearer  full  term  there  is  usually  no  disturbance  of  the 
reflex  acts  of  sucking  and  swallowing,  but  the  digestive  ferments  are  dimin- 
ished in  quantity  and  the  digestive  capacity  is  therefore  markedly  di- 
minished. The  degree  of  functional  development  of  the  gastrointestinal 
organs  of  the  premature  infant  is  of  the  very  greatest  importance  from  the 
standpoint  of  prognosis,  since  its  life  as  well  as  its  development  depends 
upon  its  capacity  to  digest  and  assimilate  sufficient  food,  not  only  to  furnish 
body  heat,  but  to  supply  nutrition  for  its  growth  and  development.  Among 
the  prominent  and  discouraging  symptoms,  therefore,  are  those  which  arise 
from  gastrointestinal  indigestion.  The  meconium  is  passed  for  five  or  six 
days,  but  after  this  normal  milk  stools  should  begin  to  appear.  If,  however, 
the  infant  fails  in  its  digestive  capacity  and  the  discharges  indicate  a 
gastroenteric  indigestion,  the  prognosis  becomes  very  grave  indeed. 

The  susceptibility  to  infection  is  increased  with  the  degree  of  imma- 
turity of  these  infants  and  this  susceptibility  depends  not  only  upon  the 
lack  of  resistance  to  pathogenic  microorganisms  due  to  a  lack  of  develop- 
ment of  the  defensive  mechanisms  by  which  normal  infants  offer  more  or 
less  resistance  to  invading  bacteria,  but  also  to  the  ease  with  which  these 
microorganisms  find  an  entrance  through  the  imperfectly  developed  skin 
and  mucous  membranes.  Alexins  and  other  antibodies  are  markedly 
deficient  in  the  premature  infant,  and  for  this  reason  it  much  more  readily 
succumbs  to  infections  which  find  entrance  through  the  umbilical  wound, 
the  skin,  mouth,  gastrointestinal  canal,  and,  perhaps  of  even  more  impor- 
tance, through  the  respiratory  passages.  Premature  infants  are  especially 
predisposed  to  all  forms  of  general  sepsis,  to  bronchopneumonia,  bronchitis, 
gastrointestinal  disorders  and  hemorrhagic  diseases  associated  with  serious 
forms  of  malnutrition. 

Very  commonly  prematurity  is  produced  by  some  severe  constitutional 
disease  in  the  mother,  such  as  syphilis  or  tuberculosis.  Infants  of  this 
type  usually  suffer  from  a  severe  form  of  hereditary  syphilis,  or  from 
pronounced  malnutritions,  which  are  quite  independent  of  the  retardation 
in  development  which  characterizes  uncomplicated  prematurity.     Infants 


TREATMENT  65 

who  are  not  only  premature  but  are  congenitally  weak  and  malnourished 
as  a  result  of  hereditary  disease  have  much  less  chance  for  attaining  normal 
development  than  has  the  infant  who  suffers  simply  from  uncomplicated 
prematurity. 

In  addition  to  the  symptoms  which  have  been  dwelt  upon  above,  pre- 
mature infants  are  markedly  underweight,  and  their  birth  weight  is  of 
great  importance  from  the  standpoint  of  prognosis.  Viable  premature  in- 
fants may  vary  in  weight  from  two  and  one-half  to  six  pounds.  Death 
almost  always  occurs  if  the  body  weight  is  less  than  two  and  one-half 
pounds.  With  the  increasing  birth  weight  of  the  infant  the  prognosis 
becomes  more  favorable.  The  skin  of  the  premature  infant  is  commonly 
slightly  jaundiced.  Its  extremities,  and  in  fact  the  whole  surface  of  its 
body,  feel  cool  to  the  touch,  and  with  the  feeble  and  shallow  respiratory 
movements  we  may  have  cyanosis,  dyspnea,  or  asphyxia. 

Prognosis. — The  prognosis  depends  largely  upon  the  rectal  tempera- 
ture and  the  possibility  of  producing  and  maintaining  a  comparatively 
normal  body  temperature  under  the  influence  of  artificial  heat.  It  depends 
also,  as  previously  stated,  upon  the  weight  of  the  infant  and  upon  its 
ability  to  take  and  assimilate  sufficient  food  to  supply  its  body  wants. 
Under  favorable  conditions  in  private  families,  where  the  infant  can  be 
at  once  properly  treated  without  first  allowing  it  to  become  chilled  and 
to  suffer  from  a  low  body  temperature  for  a  number  of  hours,  the  prognosis 
is  good.  The  majority  of  cases  born  after  the  seventh  month  and  weighing 
more  than  three  pounds  develop  into  normal,  healthy  infants.  Premature 
infants  who  are  neglected  for  the  first  twelve  hours  of  their  lives,  and  who 
perhaps  during  this  time  are  transferred  from  one  institution  to  another, 
have  greatly  diminished  chances  for  living.  The  prognosis  in  breast-fed 
premature  infants  is  vastly  better  than  in  those  which  are  fed  upon  arti- 
ficial food.  When  syphilis  and  other  forms  of  congenital  debility  are  added 
to  the  prematurity,  the  prognosis  is  for  the  most  part  unfavorable. 

Treatment. — As  premature  babies  very  commonly  suffer  from  asphyxia, 
the  earliest  treatment  of  these  cases  consists  in  clearing  the  throat  of  mucus 
and  other  fluids  and  establishing  normal  respiratory  movements  by  the 
resuscitating  measures  outlined  under  Asphyxia.  Following  the  establish- 
ment of  normal  respiration,  the  infant's  body  is  to  be  cleansed  with  oil  and 
absorbent  cotton  and  its  eyes  carefully  washed  with  a  saturated  solution  of 
boracic  acid.  It  is  then  to  be  carefully  wrapped  in  absorbent  cotton  so 
that  its  whole  body,  except  the  face,  hands  and  buttocks,  is  wholly  covered ; 
the  absorbent  cotton  should  be  held  in  position  by  gauze  bandages.  The 
object  of  thus  covering  the  infant  with  a  thick  layer  of  absorbent  cotton 
immediately  after  birth  is  to  prevent  the  sharp  fall  in  body  temperature 
which  may  occur  at  this  time.  The  buttocks  are  to  be  protected  by  sep- 
arate pieces  of  cotton  so  adjusted  as  to  catch  the  excreta  without  fouling 
the  entire  dressing.  The  cotton  dressing  above  described  is  to  be  changed 
once  in  twenty-four  hours  in  a  warm  room  with  the  infant  before  an  open 
fire.     When  the  dressing  is  removed,  before  another  similar  dressing  is 


66  THE   CARE   OF   PREMATURE    INFANTS 

applied,  the  infant's  body  is  to  be  cleansed  with  cotton  and  warm  olive  oil. 
This  form  of  dressing  should  continue  to  take  the  place  of  clothing  for 
from  one  to  three  weeks,  depending  upon  the  stage  of  immaturity  of  the 
infant.  As  soon  as  the  heat-regulating  apparatus  of  the  infant  commences 
to  assume  normal  control  of  the  body  temperature,  these  wrappings  may 
be  gradually  changed  for  the  clothing  ordinarily  worn  by  newly-born  in- 
fants. The  skin,  buttocks  and  mucous  membranes  of  the  nose  and  mouth 
should  be  kept  clean  and  free  from  irritation.  The  position  of  the  infant 
should  be  frequently  changed  so  that  no  portion  of  the  skin  Avill  l)e  sub- 
jected to  body  pressure  for  any  great  length  of  time.  This  is  important 
since  these  infants  will  lie  for  an  indefinite  length  of  time  in  one  position, 
making  no  movement  and  uttering  no  cry. 

Incubator. — The  most  important  part  of  the  treatment  is  that  of 
maintaining  an  approximately  normal  and  even  temperature  of  the  infant's 
body  by  artificial  means,  without  causing  it  to  breathe  an  overlieated  impure 
air.  This  problem  is  very  difficult  of  solution;  to  solve  it  incubators  were 
introduced  and  they  are  now  in  general  use  and  recommended  by  all 
authorities.  Only  incubators  of  the  most  approved  type  should  be  used 
and  they  require  careful  supervision  by  competent  attendants  night  and 
day.  The  heat-regulating  apparatus  of  the  best  of  incubators  may  at  times 
get  out  of  order,  and  as  a  result  the  infant  may  be  exposed  to  great  heat  or 
cold,  and  such  an  accident  may  be  fatal  to  the  incubator  infant. 

The  experience  of  pediatricians  has  been  that  an  incubator  temperature 
above  85°  F.  is  prejudicial  to  the  welfare  of  infants  and  that  they  thrive 
best  at  a  temperature  of  80°  F.  With  this  amount  of  artificial  heat  added 
to  that  which  the  infant  can  manufacture  the  rectal  temperature  of  the 
incubator  infant  should  be  between  93°  and  97°  F.  Normal  temperatures 
are  not  to  be  expected  during  the  first  or  second  weeks  of  treatment,  but 
if  the  infant's  temperature  remains  constantly  below  90°  F.  the  prognosis 
is  very  unfavorable.  It  is  advisable,  especially  in  institutional  work,  that 
the  air  supplying  the  incubator  should  come  from  the  outside,  so  as  to 
have  it  as  pure  and  as  free  from  microbic  contamination  as  possible.  Incu- 
bators, when  properly  constructed  and  carefully  watched  throughout  the 
whole  of  the  twenty-four  hours,  have  given  good  results  both  in  institutional 
and  private  practice. 

Padded  Basket. — My  own  experience  is,  in  accord  with  that  of  many 
other  pediatricians,  that  the  cotton-padded  basket  is  more  easily  managed 
and  gives  as  good  results  as  the  incubator,  especially  in  private  practice. 
In  carrying  out  this  treatment  the  premature  infant,  after  being  cotton- 
wrapped  as  above  described,  is  placed  in  a  basket,  the  inside  of  which  has 
been  previously  heavily  padded  with  cotton  and  covered  with  gauze,  and 
the  space  within  the  basket  when  thus  padded  should  be  at  least  twice  the 
length  of  the  infant,  so  that  warm  water  bottles  or  electric  heaters  can  be  so 
placed  as  to  apply  artificial  heat  to  the  child's  body  without  coming  in 
direct  contact  with  it.  The  infant  thus  covered  with  warm  blankets  and 
its  bed  warmed  by  artificial  heat  is  placed  in  a  large,  quiet,  warm,  well- 


TREATMENT  67' 

ventilated  room;  the  temperature  of  this  room  shoiUd  l)e  about  80°  F. 
If  the  room  has  an  open  fireplace  this  should  be  utilized  during  the  cold 
months  to  assist  in  warming  and  ventilating  the  room,  and  at  least  one 
window  in  the  room  should  be  partially  open  to  let  in  a  stream  of  pure 
fresh  air.  The  infant's  basket-bed  should  be  placed  in  the  warmest  part 
of  the  room,  away  from  the  draught  of  windows  and  doors.  All  persons, 
except  the  nurse  and  mother,  should  be  excluded  from  the  room,  and  above 
all  contagions  of  every  kind  are  to  be  carefully  avoided.  All  individuals 
suffering  from  slight  coryzas,  colds  in  the  head,  or  any  other  catarrhal  con- 
ditions of  the  respiratory  passages  should  be  excluded  from  the  room. 
These  infants  are  not  only  very  susceptible  to  contagions  of  all  kinds,  but 
when  once  the  contagion  is  started  they  oifer  little  or  no  resistance  to  it. 


Fig.   12. — Padded  Basket  for  Treatment  of  Premature  Infants. 

A  simple  rhinitis  or  an  ordinary  cold  may  prove  a  fatal  complication  in 
that  it  may  lead  to  ])ronchitis  or  bronchopneumonia. 

The  basket,  when  all  the  above  details  of  treatment  can  be  carefully 
carried  out,  is  safer  and,  as  I  believe,  gives  as  good  results  as  the  incubator. 
The  basket  may  also  be  used  in  institutional  work  instead  of  the  incubator 
if  the  infant  can  be  isolated  as  above  described.  This  basket  treatment, 
however,  in  the  crowded  wards  of  a  city  hospital  is  very  unsatisfactory; 
the  incubator  with  its  outside  ventilation  is  preferable  under  such  con- 
ditions. 

Feeding  of  Premature  Infants. — Breast  Feeding. — Feeding  is  of 
almost  as  much  importance  as  the  treatment  above  given  for  maintaining 
the  body  temperature  and  furnishing  fresh  air.  Every  premature  infant 
should,  if  possible,  be  fed  upon  breast  milk,  otherwise  its  chances  for  re- 
covery are  very  greatly  diminished.  Within  the  first  twenty-four  hours  the 
infant  requires  no  food;  during  this  time  a  little  water  slightly  sweetened 
with  milk  sugar  may  be  given;  this  gives  the  physician  an  opportunity 
to  find  a  wet  nurse.  The  mothers  of  premature  infants  are  not  prepared 
to  furnish  breast  milk :  the  milk  secretion  is  not  established  in  most  cases 


68 


THE   CARE   OF   PREMATURE    INFANTS 


1. 


until  a  week  or  ten  days  have  elapsed,  and  then  in  many  instances  this 
result  is  brought  about  by  the  frequent  use  of  a  breast  pump  or  by  the 
nursing  of  another  healthy  infant.  Furthermore,  even  when  the  milk 
secretion  of  the  mother  commences  to  be  established  it  contains  for  a  num- 
ber of  days  so  much  colostrum  that  it  is  not  a  suitable  food  for  a  premature 
infant.  A  wet  nurse  should  therefore  be  employed  for  two  or  three  weeks 
until  the  milk  secretion  of  the  mother  is  fully  established,  and  during  this 
time  the  infant  of  the  wet  nurse  may  be  used  to  develop  the  milk  secretion 
of  the  mother  and  at  the  same  time  to  keep  up  the  normal  supply  of  breast 
milk  in  the  wet  nurse. 

Premature  infants  are  not,  as  a  rule,  able  to  suck ;  the  breast  milk  must 
therefore  be  drawn  from  the  breasts  with  a  breast  pump  and  fed  to  the 
infant  by  means  of  a  pipette  or  some  kind  of  infant  feeder, 
such  as  that  devised  by  Breck.  If  the  child  of  the  wet 
nurse  is  not  allowed  to  nurse  its  own  mother,  the  quantity 
of  breast  milk  will  quickly  become  deficient,  Init  under  the 
stimulating  influence  of  sucking  the  quantity  of  milk  given 
by  the  wet  nurse  will  be  quite  sufficient  to  supply  both  in- 
fants. Later  the  breast  milk  of  the  mother  may  be  sub- 
stituted for  that  of  the  w'et  nurse. 

Artificial  Food. — In  the  event  that  it  is  absolutely  im- 
possible to  obtain  suitable  breast  milk  an  artificial  food 
formula  must,  of  course,  be  resorted  to.  During  the  first 
three  days  it  is  advisable  to  give  a  2  to  4  per  cent,  solu- 
tion of  milk-sugar,  and  by  the  end  of  the  third  day  closely 
skimmed  milk  may  be  added  to  the  milk-sugar  solution, 
one  part  of  skimmed  milk  to  six  parts  of  a  4  per  cent, 
milk-sugar  solution.  From  day  to  day  the  quantity  of 
skimmed  milk  may  be  increased  until  at  the  end  of  the 
week  it  is  taking  one  part  of  skimmed  milk  to  three  parts 
of  sugar  solution.  By  this  time  the  intestinal  canal  has 
been  cleared  of  meconium,  and  normal  intestinal  discharges  should  indicate 
that  the  intestinal  canal  is  in  a  condition  to  take  a  modified  milk  formula 
containing  fat  as  well  as  sugar  and  protein.  The  infant  may  then  be  given 
0.5  per  cent,  fat,  0.3  per  cent,  protein  and  4.00  per  cent,  sugar.  As  time 
goes  on  the  fat  and  protein  content  of  this  food  mixture  is  gradually  in- 
creased, so  that  by  the  end  of  the  third  week  the  infant  may  be  taking  a 
1.00  per  cent,  fat,  0.75  per  cent,  protein  and  5.00  per  cent,  sugar  mixture. 
As  the  infant  thrives  the  protein  and  fat  percentages  in  this  formula  are 
to  be  slowly  increased  according  to  the  rules  outlined  in  the  chapter  on  Ar- 
tificial Feeding. 

Quantity  of  Food. — As  both  the  breast  milk  and  the  modified  cow's 
milk  are  fed  to  these  infants  with  some  kind  of  a  feeding  tube,  the  quantity 
of  food  taken  can  be  accurately  measured.  After  the  second  or  third  day, 
when  the  feeding  with  breast  milk  is  begun,  the  infant  should  have  from 
four  to  seven  ounces  of  milk  in  twenty-four  hours.     The  quantity  given 


Fig.  13. — Breck's 
Feeding  Tube. 


ASPHYXIA    NEONATORUM  69 

will  depend  upon  the  weight  of  the  infant.  The  four  ounces  is  suitable 
for  an  infant  weighing  between  two  and  three  pounds;  the  seven  ounces 
for  an  infant  between  five  and  six  pounds.  Day  by  day  as  the  infant  grows 
older  the  quantity  of  breast  milk  is  increased,  so  that  by  the  end  of  the 
second  week  the  infant  which  began  with  four  ounces  will  be  taking  four- 
teen or  fifteen  ounces  in  twenty-four  hours,  and  the  infant  which  began 
with  seven  ounces  will  be  taking  seventeen  or  eighteen  ounces  in  twenty- 
four  hours.  The  same  quantities  of  modified  cow's  milk  may  be  given  to 
those  infants  who  are  unfortunate  enough  to  be  deprived  of  breast  milk. 
The  interval  between  the  feedings  should,  in  the  beginning,  be  one  and  one- 
half  hours.  At  the  end  of  two  weeks  this  interval  should  be  prolonged 
to  two  hours.  This  will  make  the  individual  feedings  vary  from  one-half  an 
ounce  in  the  very  small  premature  infant  to  one  ounce  or  one  and  one-half 
ounces  in  the  large  premature  infant.  As  soon  as  the  infant  is  strong 
enough  it  should  be  put  to  the  breast.  In  many  cases  it  may  be  possible 
to  obtain  a  small  but  insufficient  quantity  of  breast  milk.  In  such  cases 
mixed  feeding  should  be  resorted  to,  and  this  mixed  feeding  should  be 
followed  out  according  to  the  method  carefully  detailed  in  the  paragraph 
on  Mixed  Feeding  in  the  section  on  Artificial  Feeding  of  Infants.  All  of 
the  breast  milk  that  can  be  obtained  should  be  given  at  each  feeding  and 
this  is  to  be  supplemented  by  a  modified  milk  formula  given  at  the  same 
time  and  in  sufficient  quantity  to  make  up  the  deficiency. 

Premature  infants  which  thrive  properly  should  develop  into  normal, 
sturdy  children,  leaving  no  trace  of  weakness  as  a  result  of  their  prema- 
turity. In  the  beginning  these  children,  like  normal  infants,  lose  slightly 
in  weight,  but  after  a  week  or  ten  days  they  should  have  regained  their 
birth  weight,  and  thereafter  should  continue  to  slowly  increase  in  weight. 
In  the  beginning  a  gain  of  two  to  three  ounces  per  week  is  considered  satis- 
factory, but  after  five  or  six  weeks,  when  they  are  strong  enough  to  nurse 
the  breast  and  to  take  larger  quantities  of  milk,  their  gain  in  weight  should 
become  more  rapid. 


CHAPTER  VI 

DISEASES    OF    THE    NEW-BOEN 

ASPHYXIA  NEONATORUM 

Etiology. — Asphyxia  is  due  to  deficient  oxygenation  of  the  blood  and 
the  resulting  symptoms  are  in  part  produced  by  the  poisonous  action  on 
the  nerve  centers  of  carbon  dioxide.  As  the  infant  during  intrauterine  life 
is  dependent  upon  the  placenta  for  its  supply  of  oxygenated  blood  it  may 
be  asphyxiated  by  anything  that  interferes  with  the  placental  circulation. 
The  most  common  cause  of  this  condition  is  pressure  or  twisting  of  the 
umbilical  cord  during  labor.     The  cord  may  be  prolapsed  or  it  may  be 


70  DISEASES  OF  THE  XEW-BOKN 

wrapped  around  the  neck  or  some  other  portion  of  the  infant's  body  in 
such  a  manner  that,  during  delivery,  especially  if  it  be  prolonged,  the  cir- 
culation between  the  placenta  and  the  infant  is  cut  off  and  asphyxiation 
results.  This  is  more  liable  to  occur  during  breech  presentations  and  dur- 
ing protracted  labor  following  the  premature  discharge  of  the  liquor  amnii ; 
in  these  conditions  the  cord  is  so  firmly  pressed  against  the  body  of  the 
child  by  the  strong  uterine  contractions  that  circulation  through  it  is  im- 
peded or  entirely  obstructed.  Asphyxia  may  also  be  produced  by  cerebral 
hemorrhage,  by  defective  development,  by  the  premature  detachment  of 
the  placenta  and  by  the  death  or  serious  illness  of  the  mother  during  labor. 
If  the  child  is  asphyxiated  before  labor  begins  it  is  stillborn  and  the  extent 
of  the  maceration  of  its  skin  and  the  general  appearance  of  the  dead  fetus 
may  give  some  idea  of  the  length  of  time  it  has  been  dead. 

Asphyxiation  may  also  occur  after  birth  in  premature  and  malnourisliod 
infants  as  a  result  of  defective  development  of  the  muscular  and  nervous 
mechanisms  which  preside  over  the  respiratory  movements.  In  this  type 
the  infant,  which  has  been  kept  alive  by  the  placental  circulation  during 
intrauterine  life,  has  not  sufficient  vitality  to  establish  normal  respiratory 
movements  after  birth.  Fortunately  these  hopeless  cases  are  very  uncom- 
mon. Criminal  neglect  of  the  infant  just  after  birth  may  allow  it  to  lie 
face  downward  in  the  blood  and  mucus  which  has  been  discharged  during 
labor,  and  in  this  manner  it  may  become  asphyxiated. 

Symptomatology .^In  those  cases  where  asphyxia  occurs  during  labor 
the  carbon  dioxide  poisoning  and  the  air  hunger  bring  about  premature 
inspiratory  efforts,  and,  as  a  result,  mucus  and  other  secretions  may  be 
drawn  into  the  respiratory  passages  and  by  strangulation  increase  the  ex- 
isting asphyxia. 

The  symptom  groups  which  characterize  the  mild  and  severe  types  of 
asphyxia  are  somewhat  distinct.  The  mild  form  is  spoken  of  as  asphyxia 
livida.  In  this  condition  the  skin  is  blue  and  the  mucous  membranes  are  a 
dark  purple  color.  The  infant  lies  more  or  less  motionless,  but  is  not  limp 
or  apparently  lifeless ;  its  muscles  are  not  relaxed,  its  reflexes  are  commonly 
present,  its  pupils  are  not  dilated  and  the  action  of  its  heart  can  be  dis- 
tinctly heard  and  commonly  felt  by  placing  the  finger  over  the  location  of 
the  apex  beat.  The  infant,  however,  does  not  cry,  and  its  respiratory 
movements  are  irregular,  shallow  or  gasping. 

In  the  severe  form  known  as  asphyxia  pallida  (Runge)  the  child  at 
first  sight  is  apparently  dead.  It  has  a  pale,  pasty,  cadaverous  look  about 
its  face ;  its  lips  are  dark  blue,  its  body  and  extremities  are  cold  and  there 
is  a  general  lack  of  tone  or  flaccid  condition  of  all  the  muscles.  As  the 
child  is  lifted  its  body  seems  limp  and  lifeless,  reflexes  are  absent,  pupils 
are  dilated,  there  are  no  efforts  at  respiratory  movements,  and  the  only  evi- 
dence of  life  is  to  be  found  in  the  feeble  heart  beat,  Avhich  can  be  heard 
but  not  felt.  In  some  of  these  cases  a  few  gas])ing  efforts  at  inspiration 
may  be  made,  but  the  mucus  which  has  accumulated  in  the  throat  and 
upper  respiratory  passages  prevents  the  entrance  of  air  into  the  lungs.     It 


ASPHYXIA    NEOXATORUM  71 

is  evident  from  the  above  description  that  there  is  no  clear  line  of  demarca- 
tion between  asphyxia  livida  and  asphyxia  pallida.  The  livid  and  pale 
forms  of  this  disease  represent  but  different  grades  of  severity.  One  may 
meet  cases  of  asphyxia  so  mild  that  slight  cyanosis  and  irregularity  in 
breathing  are  the  only  symptoms,  and  again  the  case  may  be  so  severe  that 
all  efforts  at  resuscitation  fail,  and  the  clinical  picture  of  asphyxia  pallida 
is  aggravated  until  the  cessation  of  the  heart  beat  announces  the  death 
of  the  infant.  Between  these  two  extremes  we  may  have  every  grade  of 
severity. 

Diagnosis. — It  is  imj3ortant  to  remember  that  cerebral  hemorrhage  oc- 
curring during  labor  may  produce  a  symptom  group  closely  resembling 
asphyxia.  Perhaps  it  might  be  more  accurate  to  say  that  asphyxia  is  a 
part  of  the  symptom  group  in  many  of  the  cases  of  cerebral  hemorrhage. 
It  is  important,  therefore,  in  all  cases  of  asphyxia  neonatorum  to  withhold 
the  ultimate  prognosis  until  it  can  be  determined  whether  or  not  there  is  a 
coexisting  cerebral  hemorrhage;  this  can  in  most  instances  only  be  decided 
by  the  subsequent  history.  In  asphyxia,  when  respiration  has  been  estab- 
lished, the  improvement  is  very  marked,  but  while  the  child  is  weak  there 
may  be  a  tendency  to  a  slight  return  of  the  asphyxia  in  the  first  twenty- 
four  or  thirty-six  hours,  yet  under  careful  nursing  satisfactory  convalescence 
is  soon  established.  This  is  not  true  of  cerebral  hemorrhage  severe  enough 
to  produce  asphyxia.  In  these  cases  we  are  likely  to  have  localized  or  even 
slight  general  convulsions  recurring  over  a  number  of  days,  and  the  infant 
during  this  time  remains  in  a  dull  and  stupid  condition.  Thereafter  con- 
valescence, as  compared  with  that  of  uncomplicated  asphyxia,  is  very  slow. 
It  should  be  remembered  that  in  these  cases  of  cerebral  hemorrhage  one 
may  not  have  for  weeks  and  months  the  characteristic  symptoms  of  spastic 
palsy,  so  that  the  absence  of  this  palsy  in  the  newly-born  infant  suffering 
from  asphyxia  does  not  exclude  cerebral  hemorrhage. 

Prognosis. — The  prognosis  depends  largely  upon  the  character  of  the 
asphyxia  and  the  treatment  instituted.  If  well  marked  it  is  always  a 
grave  symptom.  In  general  terms,  however,  one  may  say  that  the  prognosis 
in  asphyxia  livida  is  good  if  the  cases  are  properly  treated,  and  that  the 
prognosis  in  asphyxia  pallida,  while  bad,  is  not  always  fatal.  In  cases  due 
to  cerebral  hemorrhage  the  prognosis  as  to  life  is  unfortunately  good.  I  say 
unfortunately,  since  nearly  all  of  these  cases  are  hopelessly  defective  in 
their  mental  development  (Jacohi). 

Prophylaxis. — The  preventive  treatment  of  asphyxia  is  largely  obstet- 
rical. Breech  presentations  and  tedious  labors,  especially  in  cases  where  the 
liquor  amnii  has  been  discharged  prematurely,  should  be  terminated  as 
rapidly  as  possible.  In  cases  of  this  kind,  where  asphyxia  may  be  expected 
to  result,  the  infant  immediately  after  birth  should  receive  prompt  and 
skilful  attention.  The  mucus  and  other  foreign  matter  in  its  throat  should 
be  quickly  wiped  out  with  a  moist  cloth  covering  the  finger,  and  it  should 
be  held  up  by  the  legs,  head  downward,  and  gently  shaken,  as  this  procedure 
facilitates  the  removal  of  the  inspired  fiuids  and  stimulates  by  congestion 


72 


DISEASES  OF  THE  NEW-BORN 


the  respiratory  centers.  Slapping  the  body  of  the  infant  with  a  cool  rag  or 
dipping  it  alternately  into  a  bucket  of  warm  and  cool  water  may  reflexly 
stimulate  respiratory  movements.  This  may  be  done  three  or  four  times  in 
a  minute  until  the  infant  begins  to  cry  and  more  or  less  normal  respiratory 
movements  are  established.  This  treatment  when  promptly  administered 
will  prevent  many  cases  of  asphyxia. 

Treatment.— When  the  infant  is  born  asphyxiated  the  object  first  sought 
is  to  clear  the  respiratory  passages  of  inspired  mucus  and  liquor  amnii. 
This  is  accomplished,  as  above  stated,  by  holding  the  infant  head  downward 
shaking  it,  and  at  the  same  time,  with  a  gauze-wrapped  finger,  removing 
the  mucus  and  other  fluids  from  the  throat.  If  evi- 
dences of  strangulation  still  exist  a  small,  soft,  rub- 
ber catheter,  cut  off  at  the  end,  should  be  introduced 
into  the  opening  of  the  larynx  and  the  fluids  re- 
moved by  suction  or  aspira- 
tion. In  emergency  cases  of 
this  kind  there  is  no  time  for 
the  operator  to  provide  him- 
self with  an  instrument  espe- 
cially devised  for  this  pur- 
pose, and  valuable  time 
should  not  be  lost  in  prepar- 
ing an  instrument  which  will 
protect  the  mouth  of  the  op- 
erator from  these  inspired 
fluids  which  are  being  drawn 
from  the  respiratory  passages 
of  the  infant.  These  manip- 
ulations having  been  made, 
as  quickly  as  possible,  to 
clear  the  respiratory  pas- 
sages of  fluid,  the  child  is 
placed  upon  a  bed  face  up- 
ward and  a  piece  of  gauze 
thrown  over  its  mouth;  the  physician  then,  after  closing  the  nose  of 
the  child  with  one  hand  and  making  firm  pressure  over  the  stomach  with 
the  other,  places  his  lips  to  that  of  the  infant  and  blows  air  from  his  own 
lungs  into  those  of  the  infant,  and  as  he  thus  inflates  its  lungs  he  can  see 
the  movements  of  the  chest  walls;  the  air  is  expelled  from  the  lungs  by 
pressing  upon  the  chest  wall.  This  method  of  lung  inflation  may  be  re- 
peated every  few  minutes  until  the  infant  begins  to  cry  or  makes  efforts 
at  normal  respiratory  movements;  artificial  respiration  should  then  be  re- 
sorted to. 

Artificial  Eespiration. — Schultze's  method,  which  is  recommended 
by  all  writers  upon  this  subject,  is  the  most  valuable  and  is  described  as 
follows:    The  physician,  standing,  grasps  the  infant  with  both  hands,  his 


Fig.  14. — Schultze's  Method  of  Artificial  Res- 
piration.    (After  Edgar.) 


CONGENITAL    ATELECTASIS  73 

palms  resting  upon  the  child's  shoulders,  his  thumbs  extending  over  the 
anterior  surface  of  the  chest  near  the  axilla,  his  fingers  spreading  out  over 
the  scapulae,  and  the  infant's  head,  resting  between  his  arms,  is  supported 
by  his  wrists.  The  infant,  firmly  grasped  in  this  manner,  is  swung  upward 
above  the  operator's  head;  in  doing  this  its  body  is  bent  forward,  its  ab- 
dominal viscera  pressed  upward  against  the  diaphragm  and  expiration  is 
thereby  accomplished.  The  child's  body  is  now  swung  backward  in  the  same 
circle  until  its  body  hangs  downward  with  its  spine  bent  slightly  backward ; 
with  this  movement  the  diaphragm  sinks  and  inspiration  is  accomplished. 
This  operation  is  repeated  some  ten  or  fifteen  times  a  minute  until  normal 
respiratory  movements  begin  to  be  established.  In  employing  this  method 
unnecessary  chilling  of  the  infant's  body  is  to  be  avoided  as  much  as 
possible. 

Other  methods  of  artificial  respiration  are  recommended.  A  modifica- 
tion of  the  Schultze  method  described  by  Dew  consists  in  holding  the 
infant  back  downward  in  such  a  way  that  its  body  may  be  bent  in  much 
the  same  manner  as  in  the  swinging  movements  above  described.  The  body 
of  the  child  is  alternately  flexed  and  extended  so  as  to  push  the  diaphragm, 
upward  and  pull  it  downward,  thus  producing  expiration  and  inspiration. 
These  manipulations  may  be  made,  as  Ela  recommends,  while  the  infant  is 
in  a  warm  bath,  temperature  100°  to  105°  F.  The  combination  of  warm 
bath  and  artificial  respiration  is  especially  to  be  recommended  in  asphyxia 
pallida.  Artificial  respiration  may  also  be  carried  on  in  young  infants  as  it 
is  in  older  children  by  placing  the  child,  face  upward,  in  a  prone  position 
with  its  shoulders  slightly  elevated  above  the  rest  of  its  body,  and  then 
gradually  lifting  the  arms  high  above  the  head  in  a  line  with  the  body  and 
again  bringing  them  down,  at  the  same  time  making  compression  down- 
ward and  inward  against  the  whole  anterior  and  lateral  surfaces  of  the 
chest  wall. 

Following  its  resuscitation  and  the  establishment  of  normal  respiration 
the  infant  must  be  carefully  watched  for  twenty-four  or  thirty-six  hours, 
and  in  the  event  that  signs  of  asphyxia  begin  to  recur  it  must  again  be 
subjected  to  one  or  the  other  methods  above  detailed  for  bringing  about 
normal  breathing.  The  inhalation  of  oxygen  is  sometimes  of  benefit  in  these 
recurrent  cases.  Strychnia,  1/400  or  1/500  of  a  grain,  given  hypoder- 
mically,  has  also  been  recommended  in  these  cases.  As  some  of  the  severe 
cases  are  unable  to  nurse  for  three  or  four  days,  it  may  be  necessary  to  feed 
them  with  a  medicine  dropper  and  to  give  them  occasionally  a  few  drops 
of  whiskey  well  diluted, 

CONGENITAL  ATELECTASIS 

The  lungs  of  the  infant  at  birth  are  collapsed,  contain  no  air,  or,  in 
other  words,  are  in  a  state  of  congenital  atelectasis.  With  the  first  inspira- 
tory efi'orts  the  lung  commences  to  expand.  This  is  a  gradual  process  and  a 
number  of  days  elapse  before  the  entire  lung  is  inflated.     If  any  portion 


74  DISEASES  OF  THE  NEW-BORN 

of  the  lung  fails  to  expand,  it  remains  in  its  fetal  condition  of  collapse  or 
congenital  atelectasis.  It  is,  moreover,  evident  that  the  extent  of  this  con- 
dition may  vary  greatly  from  a  slight  and  scattered  atelectasis,  which  re- 
sults simply  from  delay  in  the  inflation  of  the  lung,  to  an  atelectasis  so 
extensive  that  the  whole  of  one  lung  may  be  involved  or  such  extensive 
regions  of  both  lungs  that  life  under  these  conditions  is  impossible,  and 
the  infant  dies  from  asphyxia. 

Etiology. — All  of  the  causes  which  predispose  to  asphyxia  neonatorum 
are  also  important  factors  in  the  production  of  atelectasis.  It  occurs  in 
premature  infants,  in  feeble,  malnourished  infants,  in  those  suffering  from 
congenital  syphilis,  and  in  infants  suffering  from  cerebral  hemorrhages  and 
other  birth  injuries.  Inspired  fluids,  such  as  nuicus  and  liquor  amnii,  which 
may  be  sucked  into  the  bronchial  tree  with  the  first  inspiratory  efforts,  may 
obstruct  the  smaller  bronchi  and  prevent  the  inflation  of  the  portions  of  the 
lungs  to  which  they  carry  air.  Obstructive  atelectasis  may  also  occur  after 
normal  respiratory  movements  have  apparently  been  established.  In  such 
cases  portions  of  the  lung  which  have  been  inflated  again  return  to  their 
atelectatic  condition,  thus  producing  a  form  of  acquired  atelectasis.  These 
cases  of  acquired  atelectasis  occurring  in  the  new-born  are,  as  a  rule,  due 
to  the  plugging  of  the  bronchial  tubes  with  mucus  or  with  inflammatory 
products.  In  this  chapter,  the  acquired  atelectasis  which  occurs  in  older 
infants  as  the  result  of  bronchitis,  bronchopneumonia,  pleurisy  and  rickets, 
will  not  be  considered. 

Symptomatology. — The  symptoms  are  commonly  associated  with,  and 
practically  cannot  be  separated  from,  those  of  asphyxia  neonatorum,  or  per- 
haps one  might  more  clearly  express  this  relationship  by  saying  that  a 
greater  or  less  degree  of  asphyxia  is  a  constant  symptom  of  atelectasis. 
When  the  atelectasis  is  so  slight  as  not  to  produce  any  evidences  of  asph3'xia 
whatever,  then  it  cannot,  as  a  rule,  be  discovered  by  other  physical  signs 
and  symptoms.  The  respiratory  movements  in  atelectasis  are  defective. 
They  are  usually  irregular  and  shallow.  Sometimes  long  pauses  occur,  fol- 
lowed by  a  gasping  respiration,  with  the  resumption  for  a  time  of  irregular 
and  superficial  respirations.  The  more  pronounced  these  symptoms  the 
more  aggravated  the  case.  In  the  milder  cases  respiratory  action  is  but 
slightly  interfered  with.  In  the  most  severe  cases  complete  asphyxia  oc- 
curs. 

These  infants  are,  as  a  rule,  feeble,  somnolent  and  ominously  quiet,  not 
demanding,  and  usually  not  taking,  sufficient  nourishment.  The  tempera- 
ture is  subnormal,  the  face  pale  and  comparatively  expressionless.  On  deep 
inspiration,  which  may  be  brought  about  by  slapping  the  child  with  the 
hand,  or  applying  cool  water  to  its  chest,  one  may  hear,  at  the  base  of  the 
lungs,  crepitant  or  subcrepitant  rales.  Where  the  atelectasis  is  severe,  and 
more  marked  on  one  side  than  on  the  other,  lack  of  symmetry  in  the 
respiratory  movements  of  the  chest  wall  may  be  observed.  In  those  cases 
which  live  for  weeks  without  the  disappearance  of  all  the  symptoms  of 
atelectasis  it  is  possible  or  even  probable  that  an  afebrile,  insidious  broncho- 


SEPTIC   IXFECTION   IN  THE   NEW-BORN  75 

pneumonia  may  develop  at  any  time.    In  such  cases  the  physical  signs  of  a 
bronchopneumonia  are  commingled  with  those  of  atelectasis. 

Treatment. — The  somnolence  and  shallow,  irregular  breathing  of  these 
children  are  to  be  combated  by  much  the  same  measures  recommended  for 
the  treatment  of  mild  cases  of  asphyxia.  From  six  to  eight  times  during 
every  twenty-four  hours  these  infants  should  be  thoroughly  aroused  and 
made  to  take  a  number  of  deep  inspirations  by  dipping  them  alternately 
into  warm  and  cold  baths,  as  recommended  in  asphyxia.  In  milder  cases, 
or  as  improvement  goes  on,  the  same  result  may  be  accomplished  by  shaking 
and  slapping  the  child  and  by  wiping  its  face  and  chest  with  a  cloth 
that  has  been  dipped  in  cool  water.  As  these  infants  commonly  have  a 
subnormal  temperature  it  is  necessary  that  they  should  be  kept  in  a  com- 
paratively warm  room,  and  sometimes,  in  addition  to  this,  artificial  heat 
in  the  form  of  hot  water  bottles  placed  in  the  bed  near  the  feet  of  the 
infant  is  necessary.  The  fulfillment  of  these  conditions  makes  it  almost 
impossible  during  the  cold  winter  months  to  give  them  the  amount  of  fresh 
air  they  require;  the  windows  cannot  be  opened  and  they  cannot  be  sub- 
jected to  the  fresh  air  treatment  recommended  in  pneumonia;  for  this 
reason  oxygen  inhalations  are  of  the  very  greatest  importance.  Perhaps 
most  important  of  all  is  the  feeding  of  these  infants;  they  are,  as  a  rule, 
too  feeble  and  breathless  to  nurse  milk  from  the  breast,  and  yet  breast 
milk  is  almost  absolutely  necessary  to  their  proper  nutrition.  Feeding 
upon  artificial  food  is  not  to  be  thought  of  unless  it  be  absolutely  impossible 
to  obtain  breast  milk.  Until  the  infant  is  able  to  nurse  the  breast  milk 
should  be  drawn  with  a  breast  pump  and  fed  with  an  ordinary  medicine 
dropper.  In  such  cases  it  is  necessary,  as  a  rule,  to  employ  a  wet  nurse,  or 
to  secure  the  services  of  another  infant  to  nurse  the  breast  and  develop 
the  milk  secretion  of  the  mother. 


CHAPTER  VII 

DISEASES    OF    THE    NEW-BOEN     (Continued) 

SEPTIC  INFECTION  IN  THE  NEW-BORN 

Etiology. — This  is  an  infection  produced  by  pus-forming  organisms, 
such  as  the  streptococcus  pyogenes,  staphylococcus  pyogenes  aureus  and 
albus,  colon  bacillus,  pneumococcus,  bacillus  pyocyaneous,  and  occasionally 
by  other  microorganisms,  such  as  the  gonococcus,  bacillus  enteritidis  and 
bacillus  of  Friedlander.  When  these  microorganisms  find  their  way  into 
the  blood  and  internal  organs  of  the  infant  a  condition  of  sepsis  is  nearly 
always  produced.  Localized  lesions  of  the  umbilicus,  skin,  vagina,  eye, 
mouth,  etc.,  may  be  produced  by  these  microorganisms  without  a  general 
sepsis  supervening.  These  localized  conditions,  unless  they  be  associated 
with  a  bacteremia  or  with  inflammation  of  internal  organs  produced  by  the 


76  DISEASES  OF  THE  NEW-BOKN 

same  microorganisms,  are  not  to  be  considered  under  the  term  sepsis  as 
used  in  this  chapter. 

Newly-born  infants  are  very  prone  to  septic  infection.  In  the  first 
place,  because  as  compared  with  older  infants  and  children  the  portals  of 
entrance  for  septic  organisms  are  more  numerous  and  more  open,  and  in 
the  second  place  because  at  this  age  there  is  comparatively  little  natural 
resistance  to  these  microorganisms  when  they  have  once  found  an  entrance 
into  the  blood  or  other  deeper  tissues.  This  feeble  resistance  is  perhaps 
closely  associated  with  the  undeveloped  condition  of  lymphatic  structures 
and  with  the  comparative  deficiency  in  the  blood  at  this  age  of  antibodies 
and  other  protective  agents  with  whicli  nature  in  older  children  and  in 
adult  life  very  successfully  fights  bacterial  invasion.  Breast-fed  babies 
offer  more  resistance  to  septic  infection  than  do  those  fed  upon  artificial 
food.  This  is  perhaps  because  they  derive  from  the  milk  of  the  mother  the 
antibodies  to  which  her  partial  immunity  is  due.  Septic  infection  is  more 
common  and  runs  a  more  severe  course  in  premature  infants  or  those  who 
are  congenitally  weak  and  in  those  suffering  from  profound  malnutrition 
due  to  lack  of  proper  food,  hereditary  disease  or  other  causes. 

Portals  of  Entry. — Infection  commonly  occurs  through  the  umbilicus. 
In  a  large  percentage  of  the  cases  the  portal  of  entry  cannot  be  discovered, 
but  there  is  little  doubt  that  many  of  these  are  umbilical  in  origin.  It  is 
perhaps  wise  to  assume  umbilical  infection  in  all  doubtful  cases,  even  in 
those  in  which  the  umbilicus  appears  normal.  The  thrombi  which  form 
in  the  ligated  umbilical  veins  may  easily  become  infected  by  the  pyogenic 
organisms  associated  with  the  necrotic  disintegration  of  the  stump  of  the 
cord.  Under  such  infection  these  thrombi  break  down  into  purulent  ma- 
terial, phlebitis  results  and  the  septic  matter  in  the  umbilical  vein  finds  its 
way  into  the  general  circulation.  In  this  way  a  general  septicemia  is  pro- 
duced, and  emboli  may  be  carried  into  almost  any  organ  in  the  body,  pro- 
ducing localized  septic  processes.  The  liver,  lungs,  intestinal  canal  and 
membranes  of  the  brain  may  thus  become  infected.  The  liver,  in  fact,  bears 
the  brunt  of  the  septic  onslaught  in  all  cases  of  septic  infection  originating 
at  the  umbilicus,  as  the  blood  from  this  region  is  carried  through  the  liver 
into  the  general  circulation.  Septic  infection  may  find  entrance  through 
abrasions,  fissures  or  ulcerations  of  the  skin  or  mucous  membranes.  It  may 
be  introduced  into  the  mouth  or  nose  by  unclean  fingers  or  dirty  bath  water. 
The  lungs  and  intestinal  canal  may  be  portals  of  entrance  for  a  general 
septic  infection.  In  these  cases  it  is  believed  that  infected  mucus  and  liquor 
amnii  reach  the  lungs  during  the  first  inspiratory  movements  or  enter  the 
intestinal  canal  in  the  early  efforts  of  deglutition.  .  Septic  infection  may 
occur  through  the  ear  and  much  more  rarely  through  the  eye  and  genital 
tract. 

Source  of  the  Infection. — The  infection,  as  above  noted,  may  have  its 
origin  in  the  sloughing  of  the  stump  of  the  umbilical  cord,  but  it  is  be- 
lieved that  in  the  great  majority  of  the  cases,  even  those  which  have  their 
portal  of  entrance  through  the  umbilicus,  the  infection  comes  from  without 


SEPTIC   INFECTION  IN  THE   NEW-BORN  77 

and  tlie  umbilical  wound  is  inoculated,  in  some  way,  with  septic  organisms 
other  than  those  engaged  in  the  normal  necrotic  process  incident  to  the 
removal  of  the  stump  of  the  cord.  This  inoculation  may  occur  not  only  to 
the  umbilical  wound,  but  to  any  of  the  other  portals  of  entrance  previously 
mentioned.  The  common  sources  of  infection  are  the  vaginal  discharges  of 
the  mother,  unclean  hands  of  the  nurse  or  physician,  dirty  clothing,  con- 
taminated air  or  impure  breast  milk  and  dirty  bath  water.  In  short,  infec- 
tion may  result  from  any  agent  which  carries  septic  microorganisms  to  the 
portals  of  entrance  which  happen  to  be  open  in  the  individual  infant. 

Septic  infection  may  also  be  transferred  directly  through  the  placental 
circulation  to  the  unborn  fetus  by  a  septic  mother.  This  method  of  trans- 
mission is  comparatively  rare  and  is  of  little  etiological  importance  in  the 
disease  under  discussion.  A  large  number  of  other  microorganisms,  such 
as  the  tubercle,  the  typhoid,  the  cholera,  and  the  influenza  bacillus,  and  the 
specific  contagion  of  measles,  scarlet  fever,  pneumonia,  and  other  acute 
infections,  may  occasionally  be  transferred  from  the  mother  through  the 
placental  circulation  to  the  unborn  infant,  but  infections  such  as  these  have 
been  elsewhere  considered  and  have  no  bearing  on  the  disease  under  dis- 
cussion. 

Symptomatology. — The  clinical  syndromes  presented  by  septic  infections 
in  the  new-born  vary  greatly  and  the  symptoms  which  announce  the  onset 
of  this  condition  depend  largely  upon  the  portal  through  which  the  septic 
organisms  have  entered.  In  umbilical  infection  there  is  commonly  a  sharp 
elevation  of  temperature  followed  by  a  few  days  of  septic  fever  and  there- 
after the  temperature  may  be  normal  or  subnormal.  Jaundice  is  a  common 
and  early  symptom.  The  liver  is  generally  enlarged  and  the  umbilicus  is 
usually  inflamed  and  contains  pus,  which  may  be  seen  filling  the  umbilical 
depression,  or  may  be  caused  to  ooze  out  of  the  patulous  umbilicus  on 
pressure.  It  should  be  remembered,  however,  that  a  normal  umbilicus  does 
not  positively  exclude  umbilical  infection.  Suppuration  may  be  going  on 
in  the  thrombi  filling  the  umbilical  vein  without  external  evidence  of  such 
condition.  In  this  form  of  sepsis  abdominal  tenderness,  distention  and 
general  peritonitis  usually  develop. 

Where  the  infection  enters  through  the  skin  or  mucous  membrane  there 
is,  as  a  rule,  some  ulceration  or  abrasion  which  indicates  the  point  of 
entrance  of  the  poison.  In  such  cases  erysipelatous  eruptions,  pemphigus, 
pressure  sores,  deep  ulcerations  of  the  skin,  furuncles,  edema,  sclerema,  or 
gangrene  may  be  observed. 

Where  the  infection  enters  through  the  mouth  ulcerations  of  the  tonsils 
or  of  the  mucous  membrane  of  the  mouth  or  nose  may  be  observed.  In 
some  instances  the  mucous  membrane  is  fissured,  dry,  and  patches  of  thrush 
or  small  aphthous  ulcers  may  be  scattered  over  it. 

Where  the  lungs  are  the  portal  of  entrance  there  is  associated  with  the 
general  sepsis  an  early  bronchitis,  pneumonia,  bronchopneumonia,  pleuro- 
pneumonia, or  empyema,  so  that  the  general  sepsis  is  largely  obscured  by 
these  local  manifestations. 


78  DISEASES  OF  THE  XEW-BORX 

When  the  gastrointestinal  canal  is  the  portal  of  entrance  the  symptoms 
of  general  sepsis  are  largely  obscured  by  the  gastroenteric  infection  and 
acute  enteritis,  which  are  early  manifestations. 

When  the  ear  is  the  portal  of  entrance  symptoms  of  meningeal  irritation 
followed  by  meningitis  and  often  by  paralysis  of  the  face  or  other  muscles 
are  early  symptoms. 

Individual  Symptoms. — As  previously  noted,  the  common  portal  of 
entrance  is  the  umbilicus,  and  therefore  the  syndrome  above  noted  as  an- 
nouncing this  disease  when  it  comes  from  umbilical  infection  is  far  and 
away  the  most  common  mode  of  onset  in  septic  infections  of  the  new-born. 
This  gives  prominence  to  jaundice  as  a  symptom  of  this  disease.  Jaundice, 
however,  is  not  always  present.  In  many  cases,  as  the  disease  progresses, 
the  face  of  the  infant  presents  a  gray  and  sickly  pallor;  in  other  cases  a 
marked  cyanosis  is  present.  Purpura  occurring  as  a  fine  "petechial  rash  or 
as  large  dark-blue  spots  scattered  over  the  body  is  also  a  common  symptom 
of  advanced  sepsis. 

The  fever  is  very  irregular  and  misleading.  For  a  few  days  following 
the  onset  it  may  be  septic  in  character,  reaching  104°  or  105°  F.  at  some 
time  during  the  day,  and  falling  below  normal  at  another.  In  a  few  days, 
however,  associated  with  the  extreme  exhaustion,  which  is  characteristic  of 
this  disease,  the  temperature  may  fall  and  remain  below  normal  with  per- 
haps but  slight  variations. 

The  hemorrhagic  symptoms  of  sepsis  are  of  great  importance.  Besides 
the  purpura  above  noted,  hemorrhages  may  occur  from  nasal,  buccal,  in- 
testinal and  other  mucous  membranes.  Under  the  heading  Hemorrhages 
in  the  iSTew-Born  the  hemorrhagic  syndromes  of  sepsis,  which  present  more 
or  less  distinct  clinical  pictures,  are  described. 

Nervous  symptoms  of  sepsis  vary  greatly  in  different  cases.  As  a  rule, 
extreme  prostration  is  associated  with  apathy  and  stupor  leading  up  to 
profound  coma.  In  other  instances,  especially  where  the  meninges  and 
cerebral  centers  are  involved,  there  are  sleeplessness,  extreme  irritability, 
muscular  twitchings,  localized  paralyses  and  finally  convulsions. 

In  addition  to  the  widely  varying  symptom  group  above  detailed,  we 
may  have,  as  symptoms  of  sepsis  in  the  new-born,  purulent  arthritis,  osteo- 
myelitis, pericarditis  and,  very  rarely,  endocarditis  and  nephritis.  Albu- 
minuria, associated  with  occasional  hyalin  and  granular  casts,  is  a  very 
common  finding.     Purulent  vaginitis  and  conjunctivitis  may  occur. 

Diagnosis. — The  diagnosis  of  septic  infection  in  the  new-born  is  oft- 
times  extremely  difficult,  since  there  is  no  clearly  defined  clinical  syndrome 
which  can  be  relied  upon  to  definitely  indicate  this  disease.  The  physician, 
however,  should  always  keep  in  mind  the  fact  that  severe  and  dangerous 
gastrointestinal,  pulmonary  and  meningeal  symptoms  occurring  at  this  time 
of  life  are  strongly  indicative  of  sepsis.  The  cases  most  difficult  of  diag- 
nosis are  those  presenting  the  symptoms  of  pneumonia,  gastroenteritis  and 
meningitis.  In  the  majority  of  cases  there  is  external  evidence  either  at  the 
umbilicus  or  on  the  skin  or  mucous  membranes,  which  indicates  that  the 


PLATE  II. 


Blood  Picture  in  Dermatitis  Exfoliativa. 
(Drawn  by  Dr.  A.  E.  Osmond). 


DERMATITIS    EXFOLIATIVA 


79 


infant  may  be  suffering  from  septic  infection.  The  symptoms  which  es- 
pecially call  attention  to  this  condition  are  great  and  unexplained  prostra- 
tion, associated  with  jaundice,  septic  temperature  and  hemorrhages  of  the 
character  above  noted.  The  blood  examination  may  show  a  marked  leuko- 
cytosis. Blood  cultures  which  might  demonstrate  positively  not  only  the 
existence  of  a  general  septic  infection,  but  the  causative  organism  as  well, 
cannot  be  resorted  to  in  infants  of  this  age  as  a  routine  method  of  diagnosis. 
Prognosis. — This  is  very  grave;  nearly  all  severe  cases  rapidly  succumb. 
Death  may  occur  within  a  few  days,  or  it  may  be  postponed  for  a  week  or 
more.  Many  of  the  milder  cases,  especially  those  having  their  origin  in 
umbilical  infection,  recover.  The  prognosis  is  altogether  unfavorable  in 
the  pulmonary,  gastrointestinal  and  meningeal  cases. 

DERMATITIS  EXFOLIATIVA 

Symptomatology. — This  interesting  and  comparatively  rare  syndrome 
described  by  Eitter  was  believed  by  him  to  be  a  manifestation  of  septic 


PERCENT 

21 

22 

23 

24 

25 

26 

27 

28 

29 

30 

31 

1 

2 

PERCENT 

95 

95 

90 

90 

85 

85 

80 

80 

75 

75 

70 

>A 

70 

65 

/ 

r 

\ 

— 

^ 

65 

60 

/ 

\ 

s. 

60 

55 

A 

/ 

\, 

A 

55 

50 

A 

/ 

\ 

,       / 

'  \ 

50 

45 

/ 

V  / 

V 

\ 

/P 

>LYMORPHS 

45 

40 

> 

V 

\ 

/ 

40 

35 

/ 

/ 

"^Slj 

lALL  LYMPH 

35 

30 

/> 

/ 

30 

25 

'^ — 

— 

— » 

,^ 

"■v.. 

v,> 

25 

?0 

''^ 

20 

15 

.y 

\- 

'' 

/^> 

15 

10 

1 

^    < 

..^' 

^"^ 

-y 

\lJ 

RGE  LYMPH 

10 

5 

V 

'"V- 

^ 

-_— 

^^ 

^.^ 

5 

0 

'•*«.- 

-- '" 

"■"" 

~^  E 

)SrNOPHILE3 

0 

POLYMORPHS    . 
LARGE  LYMPH   . 
SMALL  LYMPH 
COSINOPHILEa  , 


FiQ.  15. — Blood  Chart  in  a  Case  of  Debuatitis 
Exfoliativa. 


infection  in  the  new-born.  It  makes  its  appearance  between  the  first  and 
the  third  w^eek  of  life.  In  the  beginning  the  skin  of  almost  the  entire  body 
begins  to  show  hyperemia  with  more  or  less  swelling  and  superficial  inflam- 
mation, and  fissures  appear  at  the  angles  of  the  mouth.  This  latter  symp- 
tom is  important  and  quite  characteristic  when  taken  in  connection  with 
the  general  skin  eruption.  As  the  dermatitis  proceeds  the  skin  becomes 
thicker,  more  edematous  and  covered  with  large  flaky  scales  of  epithelium, 
which  are  partly  detached  and  which  give  to  the  whole  body  a  characteristic 
scaly  appearance.  These  scales  may  be  removed  in  large  flakes,  exposing  the 
7 


80  DISEASES  OF  THE  NEW-BORTs^ 

congested  skin  beneath.  If  recovery  occurs,  as  it  does  in  some  instances, 
this  flakiness  of  the  skin  gradually  diminishes  and  in  the  course  of  a  few 
weeks  entirely  disappears.  In  the  great  majority  of  cases,  however,  the 
disease  is  associated  with  symptoms  of  general  sepsis  and  the  prognosis  in 
these  cases  is  bad.  In  a  case  recently  observed  by  me  the  dermatitis  exfoli- 
ativa occurred  as  a  symptom  of  general  sepsis  following  umbilical  infection, 
and  the  blood  picture  in  this  case  was  interesting  and  remarkable.  This 
blood  picture,  so  far  as  the  large  number  of  eosinophiles  was  concerned, 
was  perhaps  due  to  the  skin  lesion.  The  marked  leukocytosis  was  perhaps 
a  symptom  of  the  general  sepsis.  The  blood  picture  in  this  case  is  here 
presented. 

Treatment. — There  is  perhaps  no  treatment  which  materially  influences 
the  course  of  general  sepsis  in  the  new-born.  Unguentum  Crede,  as  an 
inunction,  may  be  thoroughly  rubbed  through  the  skin  twice  in  every 
twenty-four  hours;  the  technique  for  its  administration  is  given  in  detail 
in  the  chapter  on  Scarlet  Fever.  Any  disease  of  the  umbilicus  or  of  the 
skin  or  mucous  membranes  of  the  mouth  should  have  appropriate  treatment. 
In  umbilical  infection,  the  wound  is  to  be  washed  out  with  a  1  to  4  solu- 
tion of  peroxid  of  hydrogen  or  a  1  to  1,000  solution  of  bichlorid  of  mer- 
cury. Following  the  use  of  these  disinfectants  the  part  is  to  be  carefully 
dried  and  covered  with  aristol,  or  some  other  antiseptic  powder,  which  is 
held  in  place  by  a  gauze  pad  and  proper  bandages.  External  wounds  and 
ulcers  of  the  skin  should  be  treated  in  much  the  same  way.  The  infant,  if 
not  able  to  nurse,  is  to  be  fed  with  breast  milk  from  a  medicine  dropper, 
and  given  from  ten  to  fifteen  drops  of  whiskey  in  two  teaspoonfuls  of  water 
every  three  hours. 

The  prophylactic  treatment  of  this  condition  is  of  the  greatest  impor- 
tance and  is  altogether  in  the  hands  of  the  obstetrician.  The  infant  should 
be  delivered  and  handled  with  clean  hands,  and  immediately  following  its 
birth  should  be  bathed  in  clean,  warm  water,  great  care  being  taken  to 
protect  the  eyes,  the  nose  and  the  mouth  of  the  child.  If  the  obstetrician 
knows  of  vaginal  conditions  in  the  mother  which  predispose  the  unborn 
child  to  sepsis,  even  greater  care  must  be  exercised  to  prevent  infection 
during  labor;  saline  vaginal  douches  may  be  of  value  in  such  cases.  Fol- 
lowing the  tying  of  the  cord  the  umbilical  region  must  from  time  to  time 
be  carefully  inspected,  and  if  evidences  of  acute  inflammation  develop,  or  if 
pus  appears,  the  antiseptic  treatment  above  noted  for  the  relief  of  this  con- 
dition should  be  resorted  to. 

Infants  should  not  be  allowed  to  nurse  breasts  with  infected  fissures 
or  in  which  there  has  already  developed  an  abscess  or  localized  inflamma- 
tory swelling. 

ERYSIPELAS 

The  specific  organism  of  this  disease  has  not  been  isolated.  It  is  be- 
lieved to  be  an  inflammation  of  the  skin  and  mucous  membranes  produced 
by  septic  cocci,  and  the  characteristic  redness  and  edema  are  perhaps  due  to 


ERYSIPELAS  81 

the  location  of  the  septic  inflammation  in  the  skin  and  subcutaneous  tissues. 
It  is  produced  by  septic  virus  coming  in  contact  with  an  open  wound,  or 
with  some  abrasion  of  the  skin  or  mucous  membrane.  This  inoculation 
most  commonly  occurs  during  the  first  two  weeks  of  life  through  the 
umbilical  wound,  but  it  may  occur  through  abrasions  of  the  skin  and 
mucous  membranes  about  the  nose,  genitalia  and  other  portions  of  the 
body. 

Symptomatology. — Erysipelas  manifests  itself  by  a  well-marked  redness 
and  swelling  of  the  skin,  which  in  the  new-born  commonly  occur  about 
the  umbilicus.  Because  of  the  feeble  resistance  of  the  infant  to  this  dis- 
ease the  inflammation  spreads  rather  rapidly  through  the  skin  and  subcu- 
taneous tissues  around  the  umbilicus  and  over  the  lower  portion  of  the 
abdomen  and  may  extend  to  the  lower  extremities.  When  the  infection 
starts  at  the  umbilicus  the  inflammation  spreads  downward,  although  in 
some  instances  it  may  involve  the  skin  of  the  chest,  face  and  upper  ex- 
tremities. When  the  erysipelas  begins  at  the  angle  of  the  nose  or  some 
portion  of  the  face  it  spreads  rapidly  over  the  face  and  head  of  the  infant 
and  thence  downward,  involving  the  skin  of  the  chest  and  other  portions 
of  the  body.  Facial  erysipelas  in  the  infant,  unlike  that  in  the  adult,  is 
not,  as  a  rule,  limited  to  the  face  and  head. 

Erysipelas  in  the  infant  frequently  results  in  a  general  sepsis,  pro- 
ducing peritonitis,  pneumonia  and  other  septic  infections  of  internal  organs, 
and  the  subcutaneous  tissues,  more  commonly  than  in  the  adult,  are  in- 
volved in  a  phlegmonous  inflammation.  The  constitutional  symptoms  are 
usually  severe.  High  fever,  marked  prostration,  intestinal  disorders,  som- 
nolence and  even  convulsions  may  occur. 

Prognosis. — The  younger  the  child  the  more  unfavorable  the  prognosis. 
Umbilical  infections  are  commonly  more  serious  than  those  occurring  in 
other  parts  of  the  body.  In  children  over  one  year  of  age  the  prognosis 
is  usually  good,  the  disease  running  its  course  and  terminating  in  recovery 
in  much  the  same  manner  as  it  does  in  the  adult;  during  the  first  weeks 
of  life  it  is  a  very  fatal  disease.  The  great  majority  of  these  cases  die  from 
general  sepsis. 

Treatment. — The  treatment  of  erysipelas  in  the  young  infant  is  very 
unsatisfactory.  Every  effort  should  be  made  to  nourish  the  child  with 
breast  milk.  In  view  of  the  fact  that  these  cases  are  commonly  complicated 
by  intestinal  disturbances  the  infant  should  from  the  beginning  be  fed  as 
though  it  had  gastroenteritis,  and  medicines,  such  as  the  tincture  of  the 
chlorid  of  iron,  which  may  produce  gastric  disturbance,  should  not  be 
given.  Whiskey,  well  diluted,  may  be  used  throughout  the  disease.  Ichthyol 
ointment,  one  drachm  to  the  ounce  of  lanolin,  is  almost  universally  recom- 
mended as  a  local  application.  It  relieves  the  irritation  of  the  skin  and 
thereby  diminishes  the  nervous  irritability  of  the  child,  but  it  does  not  have 
any  specific  influence  in  controlling  or  checking  the  spread  of  the  inflam- 
mation. Antistreptococcic  serum  in  from  2  to  5  c.c.  doses,  given  hypo- 
dermically  at  intervals  of  six  or  eight  hours,  is  of  value  in  some  cases. 


82  DISEASES  OF  THE  NEW-BORN 

Unguentum  Crede  should  be  given  by  inunction  in  all  cases.  This  oint- 
ment should  be  thoroughly  rubbed  into  the  skin  of  the  unaffected  portions 
of  the  body  twice  in  twenty-four  hours.  I  believe  that  this  treatment  may 
be  of  material  advantage  in  controlling  the  sepsis  in  many  cases. 

HEMORRHAGES  IN  THE  NEW-BORN 

There  are  a  number  of  clinical  syndromes,  occurring  in  the  new-born, 
in  which  hemorrhage  is  the  most  striking  symptom.  All  of  these  syn- 
dromes are  believed  to  be  due  to  some  kind  of  infection,  but  they  differ 
somewhat  from  the  clinical  pictures  of  septic  infection  just  described.  It 
is  to  be  remembered,  however,  that  ordinary  sepsis  is  the  most  common 
cause  of  spontaneous  hemorrhage  in  infants  just  after  birth,  and  it  is  also 
to  be  remembered  that  hemorrhages  may  very  rarely  occur  from  congenital 
hemophilia  and  from  unknown  causes  which  are  apparently  not  septic  in 
their  origin.  In  all  of  these  conditions  the  hemorrhages  are  due  primarily 
to  impaired  blood  coagulation ;  the  exciting  traumas  are  insignificant. 

EPIDEMIC    HEMOGLOBINUEIA 

{Winclcers  Disease) 

Epidemic  hemoglobinuria,  which  is  elsewhere  noted,  is  characterized  by 
a  well-marked  hemoglobinuria,  great  depression  and  icterus.  The  urine  is 
dark  red  in  color  and  contains  besides  hemoglobin  a  small  amount  of  albu- 
min with  occasional  casts. 

ACUTE    FATTY    DEGENERATION    OF    THE    NEW-BORN 

{Buhl's  Disease) 

Acute  fatty  degeneration  of  the  new-born  is  a  rare  septic  syndrome, 
in  which  there  may  be  hemorrhages  from  the  umbilicus  or  from  the  gastro- 
intestinal, conjunctival  and  buccal  mucous  membranes,  or  petechial  hemor- 
rhages may  occur  beneath  the  skin.  Asphyxia,  icterus,  and  edema  are  com- 
monly present;  the  spleen  and  liver  are  enlarged.  There  is  early  and  pro- 
found prostration  ending  in  death  within  one  or  two  weeks.  In  this  con- 
dition the  heart,  liver  and  kidneys  undergo  a  rapid  fatty  degeneration,  and 
hemorrhages  may  occur  in  these  organs. 

HELENA    NEONATORUM 

Helena  neonatorum  is  a  term  used  to  cover  a  septic  sjudrome,  the 
characteristic  symptom  of  which  is  bleeding  from  the  gastrointestinal  canal. 
In  these  cases  blood  is  discharged  from  the  rectum  and  is  ejected  from  the 
stomach.  The  hemorrhage  occurs  during  the  first  few  days  of  life  and  the 
first  symptom  commonly  noticed  is  the  discharge  from  the  bowels  of  dark- 
red  or  black  material,  which  on  examination  is  found  to  be  blood.  In  the 
later  discharges  the  blood,  not  remaining  in  the  intestinal  canal  so  long,  is 
not  so  dark  in  color.  In  those  cases  where  the  bleeding  continues  vomiting 
of  blood  occurs  and  the  blood  continues  to  be  discharged  through  the  rectum. 


HEMORRHAGES  IN  THE  NEW-BORN  83 

The  child  becomes  more  and  more  prostrated,  its  pallor  deepens,  the  heart 
sounds  become  more  and  more  feeble,  and  death  occurs  from  exhaustion. 
There  are,  however,  a  considerable  number  of  cases  in  which  there  is  but 
little  or  no  recurrence  of  the  hemorrhage  after  birth.  In  these  cases  the 
infant  may  discharge  by  the  rectum  brown  or  black  discharges  mixed  with 
mucus  and  fecal  matter,  an  examination  of  which  shows  that  this  discolora- 
tion of  the  fecal  discharges  is  due  to  blood.  These  cases  may  run  a  benign 
course,  the  dark-brown  discharges  colored  with  blood  may  continue  from 
four  to  five  days,  gradually  diminishing  in  frequency  and  gradually  losing 
their  dark  color,  and  thereafter  the  child  may  show  no  evidence  of  disease 
of  any  kind  except  perhaps  a  slight  intestinal  indigestion,  which  may  con- 
tinue for  some  weeks.  It  is  very  questionable  whether  these  benign  cases 
are  septic  in  origin;  it  is  much  more  probable  that  the  hemorrhages  are 
due  to  injuries  received  during  birth.  Even  severe  cases  of  intestinal 
hemorrhage,  which  have  continued  for  more  than  a  week,  may  recover. 
The  bleeding  in  some  instances  stops  spontaneously,  and  the  infant  makes  a 
slow  but  satisfactory  recovery,  and  thereafter  it  may  never  manifest  any 
hemorrhagic  tendencies,  or  constitutional  taints  to  explain  the  symptoms 
from  which  it  suffered  during  the  first  days  of  life.  A  number  of  these 
cases  have  come  under  my  observation. 

CONGENITAL   SYPHILIS 

Congenital  syphilis  may  have  among  its  earliest  manifestations  hemor- 
rhages from  the  nose,  mouth  and  other  mucous  membranes.  In  fact,  when 
hemorrhage  occurs  during  the  first  days  of  life  from  the  nose  of  an  infant 
it  is  well  to  suspect  and  look  for  other  symptoms  of  congenital  syphilis.  Pro- 
nounced and  troublesome  umbilical  hemorrhages  are  nearly  always  septic 
in  their  origin. 

PROGNOSIS    OF    HEMORRHAGE 

This  depends  upon  the  location,  the  severity  and  the  cause  of  the  hemor- 
rhage. In  Winckel's  and  Buhl's  diseases  the  prognosis  is  bad.  In  ordinary 
sepsis  of  umbilical  origin  hemorrhage  is  an  unfavorable  symptom  and  com- 
monly means  a  fatal  termination.  In  hemorrhages  from  the  nose  or  buccal 
mucous  membrane  due  to  syphilis  the  hemorrhage  can  usually  be  controlled 
by  the  local  application  of  a  solution  of  adrenalin,  and  the  prognosis  will  de- 
pend upon  the  severity  and  extent  of  other  syphilitic  lesions.  In  melena 
neonatorum  (hemorrhage  from  the  gastrointestinal  canal)  the  prognosis  is 
very  grave  and  will  depend  in  part  upon  the  presence  of  other  symptoms  of 
sepsis. 

TREATMENT    OF    HEMORRHAGE 

Hemorrhages  from  the  mouth  and  nose  may  be  controlled  by  the  local 
application  of  adrenalin  solution,  and  gastrointestinal  hemorrhages  may 
sometimes  be  modified  or  controlled  by  the  internal  administration  of 
adrenalin  in  2  or  3-grain  doses  given  at  intervals  of  two  or  three  hours. 
Ten  per  cent,  sterile  gelatin  solution  injected  subcutaneously  (15  c.  c.)  has 


84  DISEASES  OF  THE  NEW-BORX 

also  been  strongly  recommended  in  these  cases.  These  infants  should  be 
kept  as  quiet  as  possible  and  no  foods  or  fluids  given  except  water  until 
the  hemorrhage  is  controlled ;  then  small  quantities  of  breast  milk  at  four- 
hour  intervals  may  be  allowed.  Cathartics  are  to  be  avoided  and  enemata 
used  only  when  it  is  necessary  to  evacuate  the  bowels. 

Hemorrhagic  diseases  in  the  new-l)orn  have  been  successfully  treated 
by  direct  transfusion  of  human  blood  (Carrel) ;  the  technique  of  this  op- 
eration, however,  is  difficult  and  for  this  reason  -it  is  not  always  practicable. 
They  have  also  been  successfully  treated  by  injections  of  the  normal  serum 
of  human  blood.  This  method  was  introduced  by  J.  E.  "Welsh  and  has 
been  used  by  many  other  observers.  The  blood  serum  is  obtained  from  hu- 
man blood  withdrawn  and  cared  for  under  sterile  conditions.  Ten  to  thirty 
c.  c.  should  be  injected  subcutaneously  two  or  three  times  a  day  as  long  as 
the  bleeding  continues,  and  the  same  treatment  should  be  resumed  if  the 
hemorrhage  returns.  Following  both  the  transfusion  of  human  blood  and 
the  subcutaneous  injections  of  human  blood  serum,  improvement  begins  at 
once  and  the  hemorrhage  is  usually  controlled  within  one  or  two  days.  In 
the  great  majority  of  these  cases  a  permanent  cure,  results ;  in  a  few,  how- 
ever, the  benefit  derived  is  of  short  duration;  the  hemorrhage  returns  and 
the  disease  goes  on  to  a  fatal  termination.  These  methods  of  treatment 
should  therefore  be  used  in  all  severe  cases  of  hemorrhagic  disease  in  the 
new-born. 

DISEASES  OF  THE  UMBILICUS 

After  ligation  the  stump  of  the  umbilical  cord  undergoes  mummifica- 
tion and  comes  off  about  the  fifth  or  the  sixth  day.  In  premature  and  con- 
genitally  weak  children  this  process  is  somewhat  delayed.  After  separation 
of  the  cord  the  skin  of  the  umbilicus  folds  inward  so  as  to  protect  and  cover 
the  umbilical  wound  until  an  epithelial  coating  makes  it  less  susceptible  to 
injury  and  infection. 

INFECTION  OF  THE  NAVEL  WOUND 
Infection  of  the  navel  wound  occurs  during  the  first  few  days  of  life, 
either  before  or  just  following  separation  of  the  stump  of  the  cord.  The 
manner  in  which  this  infection  may  occur  and  its  causes  are  discussed  under 
Septic  Infection  in  the  New-Born.  Omphalitis  may  be  mild  or  sevare. 
Redness,  swelling,  and  infiltration  of  the  umbilicus  are  here  more  or  less 
marked,  and  a  seropurulent  or  purulent  discharge  soon  makes  its  appear- 
ance. The  skin  around  the  umbilicus  may  be  excoriated  and  the  subcu- 
taneous tissues  may  become  infected  so  that  abscesses  may  form.  As  the 
inflammation  subsides  the  umbilical  pocket  may  be  the  site  of  an  ulcer; 
in  this  condition  the  parts  remain  tender,  somewhat  swollen  and  continue 
to  discharge  pus. 

Umbilical  Vegetations. — Umbilical  vegetations,  or  granuloma,  are  a  not 
uncommon  result  of  infection  of  the  umbilicus.  After  the  stump  of  the 
cord  has  fallen  off  a  small  red  granulating  mass  is  noticed,  which  gradually 
increases  in  size,  protruding  through  the  umbilical  opening.     This  small 


DISEASES  OF  THE  UMBILICUS  85 

red  tumor  is  associated  with  a  serous  discharge  not  infrequently  tinged 
witli  blood.  This  tumor  may  become  as  large  as  the  end  of  one's  finger;  it 
is  commonly  pedunculated  and  is  bright  or  dark  red  in  color. 

Gangrene  of  the  Umbilicus. — Gangrene  of  the  umbilicus  is  rare  and 
occurs  most  commonly  in  feeble,  malnourished  children.  In  this  condition 
the  umbilical  wound  assumes  the  api)earance  of  ordinary  gangrene.  The 
gangi'enous  process  spreads  not  only  into  the  surrounding  skin  and  subcu- 
taneous tissues,  but  also  involves  the  umbilical  vessels  and  produces  a  fatal 
peritonitis  or  sepsis. 

Infection  of  the  navel  wound  resulting  in  inflammatory  processes  may, 
as  previously  noted,  involve  the  umbilical  vein  and  the  umbilical  artery, 
producing  phlebitis  and  arteritis,  and  thereby  readily  leads  to  general  septic 
infection  of  the  new-born. 

Treatment  of  Infections. — The  prophylactic  treatment  is  purely  obstet- 
rical and  consists  in  the  proper  care  of  the  cord.  A  few  minutes  following 
delivery,  after  normal  respiratory  efforts  have  been  established,  and  the 
change  in  circulation  has  occurred,  the  cord  is  to  be  carefully  ligated  with 
tape  and  then  cut.  This  should  be  done  with  clean  hands  and  clean  instru- 
ments. Following  the  bathing  of  the  infant,  the  cord  is  to  be  dressed  with 
proper  surgical  precautions,  and  thereafter  redressed  as  often  as  may  be 
necessary  to  keep  the  wound  clean  and  prevent  infection.  If  more  than 
the  normal  amount  of  inflammatory  reaction  occurs  in  the  umbilical  wound, 
either  before  or  after  the  separation  of  the  stump,  it  is  to  be  carefully 
cleansed  with  a  1  to  1,000  bichlorid  solution  or  with  a  1  to  4  peroxid  of 
hydrogen  solution  and  then  covered  with  some  antiseptic  powder,  which  is 
to  be  held  in  place  by  a  pad  of  gauze,  covered  with  absorbent  cotton  and  a 
retaining  bandage.  The  importance  of  promptly  treating  all  umbilical 
infections  by  the  most  approved  surgical  methods  has  been  emphasized  in 
the  treatment  of  Septic  Infections  of  the  N"ew-Born.  Where  abscesses  occur 
they  are  to  be  opened  and  properly  drained.  Ulcers  may  be  treated  with 
weak  astringent  powders  or  they  may  be  cleansed  and  treated  with  a  y2 
per  cent,  solution  of  nitrate  of  silver.  Granuloma  should  be  cauterized  with 
the  solid  stick  of  nitrate  of  silver.  If  they  do  not  yield  to  this  treatment 
they  should  be  curetted  or  cut  away,  and  the  wound  thus  produced  covered 
with  aristol  or  some  other  antiseptic  powder,  held  in  place  by  pieces  of 
gauze  and  adhesive  plaster. 

UMBILICAL    HEMOEEHAGE 

A  slight  umbilical  hemorrhage  may  occur  from  improper  ligation  of  the 
cord,  from  its  premature  separation,  or  from  injury  to  the  umbilicus  dur- 
ing the  early  days  of  life.  Hemorrhages  of  this  character  are  easily  con- 
trolled and  are  of  little  pathological  importance.  The  change  in  the  cir- 
culation which  occurs  at  birth  so  diminishes  the  blood  pressure  in  the  blood 
vessels  of  the  cord  that  serious  traumatic  hemorrhage,  occurring  in  an 
otherwise  normal  infant,  is  always  a  matter  of  gross  negligence  on  the 
part  of  either  the  nurse  or  the  physician.    Persistent  hemorrhage  from  the 


86 


DISEASES  OF  THE  NEW-BORN 


umbilicus  which  fails  to  yield  to  simple  treatment  is  therefore  a  matter  of 
grave  import  and  indicates  serious  constitutional  disorder  which  has  af- 
fected the  capillary  circulation  of  these  parts  in  such  a  way  that  normal 
coagulation  of  the  blood  cannot  be  induced  for  the  stopping  of  the  hem- 
orrhage. Hemorrhage  of  this  character  may,  as  previously  noted,  be  a 
symptom  of  septic  infection  in  the  new-born  or  it  may  be  one  of  the  early 
manifestations  of  syphilis  or  hemophilia.  It  is  sometimes  associated  with 
pronounced  jaundice.  It  is  always  an  indication  of  profound  and  danger- 
ous constitutional  disturbances  and  is  frequently  accompanied  l)y  otlier 
evidences  of  a  general  hemorrhagic  diathesis,  such  as  hemorrhages  from 
other  mucous  membranes  and  petechial  hemorrhages  into  subcutaneous 
tissue. 

Treatment.  — The  simple  forms  are  readily  controlled  by  bandages  mak- 
ing pressure  over  the  part,  which  may  be  saturated  with  a  1  to  1,000  adrena- 
lin solution.     The  grave  forms  of  hemorrhage,  however,  are  to  be  treated 

as  recommended  under 
Septic  Infections  in  the 
New-Born.  The  syphi- 
litic cases  should  receive 
anti-syphilitic  treatment. 

UMBILICAL    HERNIA 

A  slight  dilatation  of 
the  umbilical  ring,  with 
protrusion  of  the  intes- 
tine forming  a  small  tu- 
mor the  size  of  the  end  of 
one's  little  finger,  is  very 
common  in  premature 
and  congenitally  weak  in- 
fants. It  also  occurs  in 
older  infants  who  are 
rachitic  or  exceedingly 
malnourished,  and  who 
have  suffered  from  gas- 
trointestinal disturb- 
ances, resulting  in 
marked  abdominal  dis- 
tention. Slight  hernias, 
both  umbilical  and  in- 
guinal, are  very  com- 
monly seen  in  pot-bellied, 
malnourished,  rachitic 
infants.  These  protrusions  are  greatly  aggravated  by  crying  and  coughing. 
Treatment,  — In  the  form  of  umbilical  hernia  which  makes  its  appear- 
ance just  after  birth  the  prognosis  is  good  and  the  treatment  is  simple. 


Fig.  16. — Umbilical  Hernia. 


HOLT'S   INANITION    FEVEE  87 

The  ordinary  abdominal  bandage  of  the  infant  holding  a  pad  of  gauze  over 
the  umbilicus  may  be  applied  more  snugly  than  usual.  This  is  all  that  is 
necessary  during  the  first  few  weeks  of  life.  Later  the  hernia  should  be 
reduced  and  held  within  the  abdominal  walls  by  a  strip  of  adhesive  plaster. 
This  strip  of  plaster  should  extend  across  the  abdomen  and  as  it  is  applied 
the  abdominal  walls  at  the  umbilicus  should  be  folded  in  a  vertical  direction 
over  the  umbilicus,  so  that  the  approximated  folds  held  by  the  adhesive 
plaster  cover  the  umbilicus  and  prevent  the  hernial  protrusion.  The  ad- 
hesive plaster  should  be  renewed  every  three  or  four  days,  and  if  ulceration 
or  irritation  of  the  umbilicus  or  of  the  surrounding  skin  has  occurred  the 
treatment  is  to  be  discontinued  until  these  parts  have  been  entirely  healed. 
The  hernia  in  these  cases  may  also  be  held  in  by  making  a  round  pad  of 
thin  wood  about  the  size  of  a  quarter,  covering  it  with  a  piece  of  soft  cloth 
and  holding  it  in  position  over  the  umbilicus  with  adhesive  plaster.  With 
treatment  of  this  kind  applied  over  a  period  of  five  or  six  weeks,  the  umbili- 
cal opening  commonly  closes  and  a  permanent  cure  results.  In  some  in- 
stances, especially  in  malnourished  infants,  the  hernia  persists  throughout 
infancy  and  perhaps  gradually  increases  in  size.  A  surgical  operation  is 
necessary  for  the  cure  of  these  cases. 

There  is  a  rare  and  much  more  serious  form  of  congenital  hernia,  due  to 
arrested  development.  In  these  cases  the  hernial  sac  at  birth  may  be  very 
large  and  filled  with  intestines  and  occasionally  other  abdominal  organs, 
such  as  the  liver,  spleen,  and  kidney.  These  cases  demand  immediate  sur- 
gical interference. 

MASTITIS 

Enlargement  of  one  or  both  mammary  glands  in  the  new-born  is  a  not 
uncommon  occurrence.  It  is  most  frequently  seen  during  the  second  week 
of  life.  These  swollen  glands  may  secrete  a  milk-like  substance,  and  on 
palpation  they  are  found  to  be  caked  and  more  or  less  tender.  In  the 
majority  of  instances  this  tumefaction  gradually  disappears;  the  breasts 
become  less  tender,  less  swollen,  and  by  the  end  of  the  third  week  of  life 
have  resumed  their  normal  proportions.  In  other  instances  an  infection 
of  the  gland  occurs  which  causes  it  to  become  more  inflamed,  red,  and 
swollen.  This  may  produce  a  slight  fever  and  after  a  number  of  days 
fluctuation  may  be  discovered. 

Treatment. — Previous  to  suppuration  the  swollen  breasts  are  to  be  cov- 
ered with  gauze  or  lint,  saturated  with  a  weak  solution  of  bichlorid  of 
mercury,  which  is  to  be  held  in  position  by  a  carefully  adjusted  bandage. 
When  fluctuation  is  discovered  it  is  to  be  treated  as  any  other  abscess,  by 
incision,  proper  drainage,  and  careful  cleansing  with  antiseptic  solutions, 

HOLT'S  INANITION  FEVER 

Under  the  term  "inanition  fever"  Holt  has  described  a  distinct  clinical 
syndrome  characterized  by  fever  and  nervous  irritability.  It  occurs  dur- 
ing the  first  five  days  of  life. 


88  DISEASES  OF  THE  NEW-BORN 

Etiology. — The  term  "inanition  fever,"  as  Holt  says,  is  not  a  satisfac- 
tory one.  It  is  probably  an  autointoxication,  due  to  the  failure  of  the  newly 
born  infant  to  get  sufficient  fluid  from  the  breast  to  flush  out  its  kidneys 
and  other  excretory  organs.  It  is  clearly  evident  that  the  condition  is 
commonly  due  to  a  deficiency  in  the  breast  milk.  It  disappears  quickly 
when  the  milk  secretion  is  established  or  when  the  infant  is  given  water  in 
sufficient  quantities.  Apart  from  determining  the  exact  pathological  cause 
of  this  syndrome  there  is  little  to  add  to  the  very  clear  description  of  its 
etiology,  symptomatology,  and  treatment  as  given  by  Holt. 

Symptomatology. — Holt  says :  "The  symptoms  are  so  uniform  and  so 
characteristic  that  they  make  for  these  cases  of  fever  a  class  by  themselves. 
The  frequency  with  which  this  is  seen  is  shown  by  the  following  statistics: 
Among  two  hundred  infants  taken  successively  at  the  Nursery  and  Child's 
Hospital  twenty  had  fever  during  the  first  five  days,  reaching  101°  F.  or 
over,  which  was  not  explained  by  ordinary  causes.  In  five  hundred  suc- 
cessive children  born  at  the  Sloane  Maternity  Hospital  there  were  one  hun- 
dred and  thirty-five  with  a  similar  fever.  It  was  seen  in  vigorous  infants 
as  well  as  in  those  who  were  delicate.  The  usual  duration  of  the  fever  was 
three  days,  the  temperature  generally  reaching  the  highest  point  upon  the 
third  or  fourth  day  of  life.  In  about  two-thirds  of  the  cases  the  tempera- 
ture did  not  rise  above  102°  F. ;  in  nine  it  was  104°  F.  or  over,  the  highest 
recorded  being  106°  F.  The  fall  was  generally  quite  abrupt,  although  not 
always  so.  Daily  weighings  showed  that  the  infant  continued  to  lose 
weight  while  the  fever  continued  and  that  the  loss  almost  invariably  ex- 
ceeded by  several  ounces  that  of  children  who  had  no  fever.  The  maximum 
loss  noted  was  twenty-eight  ounces.  In  quite  a  large  number  of  cases  it 
exceeded  twenty  ounces.  As  a  rule,  the  infant  began  to  gain  in  weight 
when  the  temperature  remained  at  the  normal  point,  but  not  until  then. 

"The  symptoms  presented  by  these  infants  were  a  hot,  dry  skin,  marked 
restlessness,  dry  lips,  and  a  disposition  to  suck  vigorously  anything  within 
reach.  With  very  high  temperature  there  was  considerable  prostration  and 
weakened  pulse.  In  the  less  severe  cases  there  were  only  crying  and  rest- 
lessness. The  rapidity  with  which  the  symptoms  disappeared  when  the 
children  were  wet-nursed  or  properly  fed  was  very  striking." 

In  addition  to  this  symptom  group  I  have  commonly  observed  in  these 
cases  a  marked  diminution  in  the  urinary  secretion  and  occasionally  anuria 
over  a  period  of  twenty-four  or  thirty-six  hours,  to  be  followed  by  the  dis- 
charge of  a  small  quantity  of  highly  colored  urine,  occasionally  tinged  with 
blood. 

Diagnosis. — This  condition  can  scarcely  be  mistaken  for  anything  except 
sepsis  in  the  new-born.  Holt's  fever  occurs  during  the  first  five  days  of 
life;  sepsis  occurs  most  commonly  during  the  second  week  and  occasionally 
later.  The  promptness  with  which  Holt's  fever  responds  to  proper  treat- 
ment and  the  seriousness  of  the  septic  syndrome  with  continuance  of  the 
fever,  prostration,  and  other  associated  symptoms  make  the  diagnosis 
clear. 


TETANUS    NEONATORUM  89 

Prognosis. — This  is  good.  All  of  these  cases  make  a  satisfactory  re- 
covery as  soon  as  the  proper  treatment  is  instituted. 

Prophylaxis. — In  view  of  tlie  prevalence  of  this  condition,  all  infants 
during  the  first  few  days  of  life  should  be  given  small  quantities  of  water 
at  frequent  intervals  and  special  attention  should  be  given  to  the  condition 
of  the  mother's  breasts,  to  ascertain  whether  the  milk  secretion  is  being 
established  at  the  normal  time.  In  cases  where  there  is  a  delayed  estab- 
lishment of  the  milk  secretion  weak  solutions  of  skimmed  milk,  1  to  4,  or 
breast  milk  should  be  given  until  the  milk  secretion  of  the  mother  has  been 
fully  established. 

Treatment. — The  curative  treatment  of  this  condition,  as  Holt  has  said, 
is  to  give  the  infant  water  at  short  intervals  and  to  supply  it  with  food  in 
the  form  of  breast  milk  from  a  wet-nurse  or  with  weak  mixtures  of  cow's 
milk.  In  the  event  that  the  secretion  of  milk  in  the  mother's  breast  is  not 
properly  established,  the  infant  should  be  fed  permanently  upon  the  breast 
milk  of  a  properly  selected  wet-nurse. 


CHAPTEE   VIII 

DISEASES    OF    THE    NEW-BORN     (Continued) 

TETANUS  NEONATORUM 

Tetanus  of  the  new-born,  like  tetanus  in  the  adult,  is  an  acute  infection 
produced  by  the  tetanus  bacillus. 

Etiology. — The  tetanus  bacillus  finds  its  portal  of  entrance  at  the  um- 
bilical wound,  and  in  this  pocket  it  multiplies  rapidly  and  forms  its  specific 
toxin  (tetanotoxin),  which  is  rapidly  disseminated  throughout  the  body. 
The  tetanus  toxin  has  a  special  predilection  for  nerve  tissue  and  probably 
unites  in  organic  combination  with  the  material  forming  the  motor  cells 
of  the  spinal  cord  and  medulla.  This  produces  an  intense  reflex  excitabil- 
ity and  irritability  of  the  motor  cells  of  the  spinal  cord  and  of  the  medulla 
oblongata.  The  irritability  of  these  tissues  becomes  so  great  that  the 
slightest  reflex  cause  will  excite  violent  tonic  muscular  contractions.  The 
tetanus  bacillus  is  believed  to  confine  itself  almost  entirely  to  the  umbilical 
pocket  and  there  produce  the  toxin,  the  absorption  of  which  is  responsible 
for  the  profound  toxic  symptoms  of  this  disease.  The  fact,  howef er,  that 
the  blood  of  patients  suffering  from  tetanus  is  capable  of  transmitting  the 
disease  when  injected  into  animals  indicates  that  along  with  the  toxin  thus 
injected  there  must  be  at  least  a  few  tetanus  bacilli. 

The  tetanus  bacillus  is  found  in  the  superficial  layers  of  the  earth  and 
is  much  more  prevalent  in  some  localities  than  in  others. 

Tetanus  is  most  common  among  the  class  of  people  who  live  in  un- 
cleanly surroundings.  It  is  a  dirt  or  filth-borne  disease  and  is  carried  to 
the  umbilicus  by  dirty  hands,  dirty  clothing,  or  by  anything  that  may  carry 


90  DISEASES  OP  THE  NEW-BORN 

dust  or  other  dirt  to  the  wound.  With  individuals  living  amidst  dirty 
surroundings  it  is  possible  that  the  tetanus  bacillus  may  be  carried  through 
the  air  on  particles  of  dust  to  the  umbilical  wound,  which,  especially  after 
the  stump  of  the  cord  has  been  separated,  furnishes  so  suitable  a  soil  for  its 
growth.  In  rare  instances  the  tetanus  bacillus  may  find  an  entrance 
through  wounds  or  raw  surfaces  other  than  that  of  the  umbilicus,  but  that 
this  is  a  very  unusual  occurrence  is  indicated  by  the  fact  that  tetanus  in 
the  young  infant  is  confined  almost  exclusively  to  the  first  three  weeks  of 
life,  when  the  umbilical  wound  is  still  open.  It  may  occur  during  the 
first  days  of  life,  but  is  much  more  common  during  the  second  week,  when 
the  cord  has  separated  and  the  umbilical  wound  is  open.  It  becomes  less 
frequent  during  the  third  week  of  life  as  all  irritation  about  the  umbilicus 
gradually  disappears,  and  after  the  third  week,  with  the  umbilical  wound 
entirely  healed,  it  is  very  rare. 

Symptomatolo^. — Nervousness,  irritability,  and  sleeplessness  are  the 
usual  premonitory  symptoms.  These  are  followed  by  difficulty  in  nursing; 
the  child  lets  go  of  the  breast  with  a  sudden  cry  after  a  few  attempts  at 
sucking.  The  lower  jaw  gradually  loses  its  motility  and  in  putting  the 
child  to  the  breast  it  is  noticed  that  there  is  a  firm  and  tonic  contraction  of 
the  muscles  which  causes  it  to  become  locked  in  such  close  proximity  to 
the  upper  jaw  that  food,  water,  and  medicines  can  be  introduced  into  the 
mouth  only  by  means  of  a  medicine  dropper.  This  condition  of  trismus  is 
an  early  and  characteristic  symptom  in  practically  every  case  of  tetanus 
neonatorum.  In  the  beginning  these  muscular  spasms  are  followed  by 
periods  of  relaxation,  hut,  on  attempting  to  feed  the  infant  by  putting  the 
nipple  or  a  spoon  betw^een  its  gums,  the  lower  jaw  is  again  thrown  into  a 
condition  of  spasm.  These  attacks  of  trismus  continue  to  recur  with 
greater  frequency  and  are  more  prolonged  as  the  disease  advances,  so  that 
within  a  short  period  of  time,  usually  a  few  days,  the  lower  jaw  is  con- 
tinuously locked  in  close  proximity  to  the  upper  jaw  by  the  tonic  muscular 
contractions. 

Spasms  of  the  muscles  of  the  face,  which  soon  become  associated  with 
the  trismus,  produce  a  very  characteristic  expression.  The  forehead  is 
wrinkled,  the  eyes  closed,  and  the  mouth  puckered.  Gradually  the  muscles 
of  the  neck,  back,  abdomen,  and  extremities  are  affected,  and  the  tetanic 
contraction  of  these  muscles  produces  retraction  of  the  neck,  opisthotonos, 
and  stiffness  of  the  entire  body.  All  the  joints  of  the  arms  and  legs  are 
in  a  condition  of  flexion.  The  muscular  rigidity  reaches  its  maximum  in 
from  one  to  three  days.  In  severe  cases  the  child  may  die  before  the  lower 
extremities  are  involved  or  in  mild  cases  recovery  may  occur  without  the 
disease  extending  to  the  arms  and  legs.  Swallowing  becomes  more  difficult 
and  finally  impossible;  respiration  is  embarrassed  as  a  result  of  spasm  of 
the  diaphragm.  Throughout  the  disease  the  tetanic  contractions  are 
greatly  exaggerated  by  slight  reflex  causes,  such  as  attempting  to  feed  the 
child  or  handling  it  for  absolutely  necessary  purposes. 

The  temperature  is  of  no  diagnostic  value.     At  the  onset  and  just  before 


TETANUS    NEONATORUM  91 

death  it  may  be  as  hign  as  105°  or  106°  F.  During  the  course  of  the  dis- 
ease it  may  be  subnormal.  The  child  lies  in  the  rigid  condition  above 
described,  making  no  outcry  because  of  the  spasm  of  the  laryngeal  muscles ; 
its  breathing  becomes  more  and  more  superficial  and  irregular;  its  pulse 
more  feeble  and  rapid;  the  muscles  of  its  body  become  more  continuously 
and  more  rigidly  contracted,  until  death  occurs  from  asphyxia  or  exhaus- 
tion. In  those  cases  which  are  fortunate  enough  to  recover  there  is  a 
gradual  recession  of  the  symptoms,  tlie  period  of  relaxation  between  the 
spasms  becomes  greater  and  the  trismus  is  less  marked,  and  the  child  less 
readily  responds  to  reflex  excitation. 

Diagnosis. — There  should  be  no  difficulty  in  the  diagnosis  of  tetanus  in 
infancy.  The  only  conditions  for  which  it  may  be  mistaken  are  meningitis 
and  brain  injuries  producing  spastic  paralysis,  and  sometimes  opisthotonos, 
but  in  these  cases  the  characteristic  symptom  of  trismus  is  absent  and  the 
tonic  muscular  contractions  do  not  recur  in  spasms  excited  by  slight  reflex 
stimuli. 

Prognosis. — Nearly  all  of  these  cases  die.  By  some  writers  the  per- 
centage of  recovery  is  placed  as  high  as  30  per  cent,  and  others  report  only 
2  or  3  per  cent,  of  recoveries. 

Treatment. — The  prophylactic  treatment  pertains  to  the  care  and  man- 
agement of  the  stump  of  the  cord  and  of  the  navel  wound  which  results 
from  its  sloughing  off.  This  treatment  is  of  special  importance  in  infants 
who  are  born  under  dirty  surroundings;  that  is  to  say,  under  conditions 
where  there  is  a  probability  or  possibility  that  the  navel  wound  may  be 
inoculated  with  filth,  dust,  or  dirt  containing  the  tetanus  bacillus.  The 
prophylactic  treatment,  therefore,  is  purely  obstetrical,  and  all  of  the  con- 
ditions necessary  to  absolute  asepsis  should  be  rigidly  enforced  in  cutting 
the  cord,  ligating  the  stump,  and  dressing  the  wound.  All  of  this  must 
be  done  with  clean  hands,  clean  instruments,  and  afterward  the  navel  is  to 
be  so  dressed  with  a  dry  antiseptic  dressing  that  it  is  impossible  for  it  to 
be  contaminated  by  dirty  surroundings.  It  is  especially  important  to  re- 
member that  the  navel  wound  is  to  be  dressed  and  redressed  for  three 
weeks,  or  until  it  has  entirely  healed.  It  is  during  the  second  week  after 
the  cord  has  sloughed  off  that  the  navel  is  to  be  especially  protected  from 
contamination  with  anything  that  may  act  as  a  carrier  of  the  tetanus 
bacillus.  If  infection  of  the  umbilical  wound  occurs  it  is  to  be  carefully 
washed  out  with  a  1  to  4  solution  of  peroxid  of  hydrogen  or  a  1  to  1,000 
solution  of  bichlorid  of  mercury,  then  carefully  dried,  and  dressed  with 
some  antiseptic  powder. 

In  the  treatment  of  the  disease  itself  it  is  wise  to  use  tetanus  anti- 
toxin with  the  onset  of  the  first  symptoms.  This  antitoxin  can  do  no 
harm  even  in  large  doses.  It  acts  by  combining  with  the  toxins  of  this 
disease  and  thereby  neutralizing  their  poisonous  effect  upon  the  nerve 
centers.  To  be  of  benefit,  therefore,  it  must  be  given  early  and  in  large 
doses.  It  is  commonly  introduced  by  lumbar  puncture  into  the  spinal 
canal  or  into  the  subcutaneous  tissues  in  the  same  way  as  diphtheria  anti- 


92  DISEASES  OF  THE  NEW-BORN 

toxin.  From  5  to  10  c.  c.  may  be  introduced  into  the  spinal  canal,  follow- 
ing a  lumbar  puncture  which  has  drained  away  that  amount  of  fluid.  The 
technique  of  this  operation  is  exactly  the  same  as  that  used  for  introducing 
anti-meningitis  serum  in  cerebrospinal  meningitis.  At  the  same  time  10 
or  more  c.  c.  of  antitoxin  may  be  introduced  subcutaneously.  The  subcu- 
taneous injection  may  be  repeated  at  intervals  of  six  hours  and  the  spinal 
canal  injection  at  intervals  of  twenty-four  hours  for  two  or  three  days.  If 
no  appreciable  result  has  then  been  produced  by  the  treatment  it  should 
be  discontinued. 

The  symptomatic  treatment  consists  in  keeping  the  child  as  quiet  as 
possible,  touching  it  only  when  necessary,  and  shielding  it  from  all  noises. 
Its  nourishment  should  be  breast  milk.  When  it  can  no  longer  nurse  the 
breast  it  should  be  fed  breast  milk  with  a  medicine  dropper,  or  the  same 
food  may  be  introduced  into  the  stomach  through  a  catheter  which  is 
passed  through  the  nose  and  down  the  esophagus.  When  these  children, 
however,  have  reached  a  stage  when  deglutition  is  impossible,  little  is  to  be 
accomplished  from  introducing  food  in  this  way. 

Chloral  is  by  far  the  most  valuable  drug  for  controlling  the  muscular 
contractions  and  making  the  patient  more  comfortable.  It  is  to  be  given 
in  1  or  2-grain  doses  every  two  or  three  hours,  as  indicated,  to  relieve  the 
symptoms.  When  the  infant  can  no  longer  swallow,  chloral,  in  2  to  4- 
grain  doses,  should  be  given  by  the  rectum.  In  milder  cases  bromid  of 
potash  may  be  used  with  or  instead  of  the  chloral. 

ICTERUS  NEONATORUM 

This  is  the  form  of  jaundice  so  common  in  the  new-bom.  It  runs  a 
benign  course  and  is  of  importance  from  the  standpoint  of  differential 
diagnosis.  It  must  be  differentiated  from  the  grave  forms  of  jaundice 
due  to  occlusion  of  the  bile  ducts  and  to  the  jaundice  which  occurs  as  a 
symptom  of  sepsis  and  cirrhosis  of  the  liver. 

Etiology. — The  etiology  of  icterus  neonatorum  remains  obscure,  not- 
withstanding the  many  ingenious  theories  which  have  been  offered  in  its 
explanation.  It  has  been  suggested  that  the  excessive  destruction  of  red 
blood  corpuscles  during  the  first  days  of  extrauterine  life  and  the  abundant 
blood  supply  to  the  liver  at  this  time  cause  the  liver  to  form  an  excess  of 
bile,  part  of  which  is  reabsorbed,  passes  into  the  blood  stream  and  produces 
jaundice.  A  part,  however,  of  this  excess  of  bile  passes  through  the  bile 
ducts  into  the  intestine,  and  for  this  reason  the  intestinal  symptoms,  which 
are  such  an  important  part  of  the  symptom  complex  in  obstructive  jaundice, 
are  almost  or  entirely  absent  in  this  condition.  This  form  of  jaundice  can 
scarcely  be  spoken  of  as  a  pathological  condition,  since  it  is  the  result  of 
physiological  causes  acting  under  new  and  perhaps  exaggerated  conditions. 
It  occurs  to  a  greater  or  less  degree  in  from  60  to  80  per  cent,  of  all  newly 
born  infants,  and  some  observers  place  this  percentage  even  higher.  It  is 
more  common,  or  at  least  more  severe  and  prolonged,  in  feeble,  mainour- 


ICTERUS  NEONATORUM  93 

ishecl  infants,  and  especially  in  those  horn  prematurely.  For  this  reason 
it  is  more  commonly  seen  in  public  maternity  hospitals  and  foundling  in- 
stitutions than  in  private  practice. 

Symptomatology. — The  jaundice  may  appear  a  few  hours  after  birth, 
but  is  commonly  not  recognized  until  the  second  or  third  day.  It  remains 
at  its  height  but  a  few  days  and  then  begins  to  slowly  disappear,  so  that  in 
the  great  majority  of  cases  no  trace  of  it  is  left  after  the  eighth  or  ninth 
day.  In  some  instances,  however,  the  jaundice  may  persist  for  several 
weeks.  This  is  much  more  likely  to  occur  in  premature  and  malnourished 
infants.  The  sallowness  makes  its  appearance  first  on  the  face,  chest,  and 
back,  and  in  the  more  marked  cases  the  yellow  color  deepens  and  the  jaun- 
dice extends  to  other  parts  of  the  body.  The  constipated,  putrid,  clay- 
colored  stools,  so  characteristic  of  obstructed  jaundice,  are  nearly  always 
absent.  The  discharges  from  the  intestinal  canal  are  almost  normal,  or 
perhaps  modified  in  the  more  marked  cases  by  slight  intestinal  indigestion. 

The  conjunctiva  is  slightly  tinged  with  yellow,  but  not  so  markedly  as 
in  obstructive  jaundice.  The  diagnosis  in  this  form  of  jaundice  is  made 
rather  by  the  sallowness  of  the  skin  than  by  the  yellowness  of  the  con- 
junctiva. When  the  jaundice  is  at  its  height,  however,  in  the  marked 
cases,  the  conjunctiva  has  a  distinctly  yellow  color.  The  urine  in  such 
cases  is  dark  in  color  and  produces  a  dark  yellow  stain  on  the  napkins,  and 
bile  can  sometimes  be  demonstrated  in  it  by  the  ordinary  chemical  tests. 
The  discoloration  of  the  urine,  however,  and  its  reaction  to  the  ordinary 
tests  for  bile  is  never  so  marked  in  this  condition  as  in  obstructive  jaundice, 
and  early  and  late  the  urine  may  furnish  no  evidences  of  containing  bile. 

Infants  with  icterus  neonatorum  present  no  constitutional  symptoms  of 
illness.  They  are,  as  a  rule,  happy,  take  their  food  in  a  normal  manner, 
and,  apart  from  the  evidences  of  jaundice  above  given,  are  apparently  well. 
The  fact  that  premature  infants  and  infants  suffering  from  more  or  less 
profound  malnutritions  have  a  more  marked  and  more  prolonged  icterus 
is  an  evidence  that  these  conditions  exaggerate  the  jaundice,  rather  than 
that  the  jaundice  aggravates- the  malnutritions. 

Treatment. — This  condition  runs  a  benign  course,  terminates  in  recov- 
ery, and  is  perhaps  not  influenced  by  therapeutic  measures.  It  is  wise, 
however,  in  these  cases  to  clear  out  the  intestinal  canal  with  a  little  chalk 
mercury,  followed  perhaps  by  milk  of  magnesia. 

OCCLUSION    OP    THE    BILE    DUCTS 

Occlusion  of  the  bile  ducts  in  the  new-born  is  rare;  it  may  be  due  to 
catarrh  of  the  mucous  membrane  or  congenital  malformations.  The  most 
common  malformation  is  obliteration  of  the  common  gall  duct;  in  some 
instances  this  duct  may  not  be  entirely  absent,  but  almost  occluded.  The 
cystic  duct  and  gall  bladder  may  be  rudimentary  or  absent. 

Symptomatology. — The  symptoms  are  those  of  obstructive  jaundice. 
The  sallowness  of  the  skin  becomes  a  deeper  and  more  pronounced  yellow 
and  the  whole  body  has  a  markedly  jaundiced  hue.     In  rare  cases  where  the 


94  DISEASES  OF  THE  XEW-BORN 

obstruction  is  not  complete  the  jaundice  may  not  be  so  pronounced  and  may 
vary  in  degree  from  time  to  time.  These  are  the  cases  which  may  live  for 
months,  slowly  dying  of  malnutrition.  In  the  great  majority  of  instances, 
however,  the  pronounced  yellowness  of  the  skin  is  associated  with  a  well- 
marked  yellowness  of  the  conjunctiva;  the  urine  contains  bile,  which  may 
readily  be  demonstrated  by  ordinary  chemical  reactions,  it  is  dark  in  color 
and  stains  the  napkin  a  yellowish  brown.  The  discharges  from  the  intestine 
gradually  become  clay  colored,  have  an  offensive  odor,  and  are,  as  a  rule, 
dry  and  constipated.  The  liver  is  enlarged  and  not  infrequently  the  spleen 
may  be  easily  palpated.  The  child  loses  in  weight  and  strength  and  pre- 
sents every  appearance  of  being  extremely  ill.  Indigestion  and  intestinal 
toxemia  with  an  associated  elevation  of  temperature  are  commonly  present. 
As  the  malnutrition  progresses  the  child  becomes  listless  and  lethargic  and 
not  infrequently  develops  a  hemorrhagic  diathesis.  Bleeding  may  occur 
from  mucous  membranes  and  purpuric  spots  may  appear  over  the  body. 
These  infants  commonly  die  from  malnutrition  or  autointoxication  within 
a  few  weeks;  in  the  less  severe  cases  death  may  be  postponed  for  some 
months.  The  rare  cases  of  catarrhal  jaundice  may  be  prolonged  for  weeks 
and  ultimately  recover. 

OTHER   FORMS    OF   ICTERUS    OCCURRING    IN    THE    NEW-BORN 

Jaundice  is  a  symptom  of  septicopyemia  occurring  in  the  new-bom. 
The  jaundice  due  to  this  cause  is  considered  under  Septic  Infection. 

Jaundice  may  also  occur  as  a  symptom  of  congenital  syphilis  in  the 
new-born.  This  is  a  comparatively  rare  cause  at  this  period  of  life.  The 
jaundice  in  this  condition  is  due  to  cirrhosis  of  the  liver.  The  interstitial 
hepatitis  compresses  the  bile  ducts  and  interferes  with  the  outflow  of  bile. 
The  symptoms  in  this  form  of  jaundice  resemble  those  of  the  milder  forms 
of  obstructive  jaundice  produced  by  congenital  occlusion  of  the  bile  ducts. 
The  skin,  conjunctiva,  and  urine  show  the  ordinary  signs  of  jaundice  and 
a  hemorrhagic  tendency  may  develop  late  in  the  disease;  the  clinical  pic- 
ture produced  does  not  in  the  least  resemble  icterus  neonatorum.  It  is  to 
be  differentiated  from  congenital  obliteration  of  the  bile  ducts  by  its  slower 
onset,  less  severe  and  more  prolonged  course,  but  more  especially  by  the 
existence  of  other  evidences  of  congenital  syphilis. 

The  prognosis  of  syphilitic  jaundice  is  bad.  Antisyphilitic  treatment 
may  prolong  but  it  cannot  save  the  lives  of  these  infants. 

OPHTHALMIA  NEONATORUM 

Ophthalmia  neonatorum  is  an  inflammation  of  the  conjunctiva  occur- 
ring in  the  new-born. 

Etiology. — The  gonococcus  is  the  cause  of  this  disease  in  perhaps  70  to 
80  per  cent,  of  all  cases.  Infection  of  the  conjunctiva  with  other  pus- 
forming  organisms,  such  as  streptococci,  staphylococci,  and  pneumococci,  is 
responsible  for  the   remaining  cases.     Infection   results   from   the   direct 


OPHTHALMIA  NEON^ATORUM  95 

inoculation  of  the  conjunctiva  with  one  or  the  other  of  these  pus-forming 
organisms  and  usually  occurs  during  the  birth  of  the  child. 

Gonococcus  and  other  forms  of  vaginitis  and  urethritis  in  the  mother 
may  produce  this  disease  in  the  infant.  Occasionally  infection  may  be 
carried  to  the  conjunctiva  of  the  infant  by  the  hands  of  the  obstetrician  or 
nurse,  either  during  or  after  labor. 

Postpartum  infection  is  comparatively  rare  and  is  due  to  gross  care- 
lessness or  negligence  on  the  part  of  those  who  have  the  care  of  the  infant. 
This  is  much  more  likely  to  occur  in  hospitals  and  other  institutions  than 
in  private  families,  but  the  transference  of  septic  infection  from  other 
patients  to  the  eyes  of  healthy  infants  is  now  fortunately  rare,  even  in 
public  lying-in  institutions  and  foundling  asylums. 

Symptomatology.  — Since  infection  nearly  always  occurs  during  birth 
the  symptoms  commonly  make  their  appearance  before  the  fourth  day.  If 
conjunctivitis  develops  after  the  fifth  day  it  is  almost  certainly  due  to  post- 
natal inoculation.  The  disease  announces  itself  with  redness  and  swelling 
of  the  conjunctiva  of  one  or  both  eyes.  Very  commonly  the  eyelids  be- 
come so  sw^ollen  and  edematous  that  the  eyes  are  closed  and  the  infant  no 
longer  has  the  power  of  opening  them.  Through  the  palpebral  fissure 
there  issues  a  thin,  yellowish  discharge.  When  the  lids  are  pressed  apart 
by  the  fingers  both  the  ocular  and  palpebral  conjunctiva  are  seen  to  be 
violently  inflamed,  much  swollen,  gathered  in  folds,  and  covered  with  a 
purulent  mucus.  The  folding  of  the  conjunctiva  is  especially  noticeable, 
where  it  crowds  over  the  corneal  margin.  As  the  disease  progresses  the 
eye  becomes  more  swollen  and  the  discharge  changes  to  a  yellow,  creamy 
pus  which  exudes  in  great  profusion  as  the  palpebral  fissure  is  opened.  At 
this  stage  of  the  disease  there  is  great  danger  that  ulceration  of  the  cornea 
may  occur.  These  ulcers  may  be  central  or  marginal,  the  latter  may  be 
hidden  beneath  the  folds  of  the  overhanging  conjunctiva.  The  appearance 
of  corneal  ulcers  adds  great  gravity  to  the  case.  These  ulcers  may  per- 
forate, and  prolapse  of  the  iris,  loss  of  the  aqueous  humor,  and  panophthal- 
mitis with  permanent  loss  of  vision  may  result.  This  disease  is,  in  fact, 
responsible  for  about  30  per  cent,  of  the  cases  of  blindness  found  in  public 
institutions.  In  those  cases  that  recover  under  suitable  treatment,  without 
corneal  involvement,  the  first  favorable  indications  are  gradual  decrease  in 
the  swelling  and  thickening  of  the  lids.  The  palpebral  fissure  is  more 
readily  opened  and  the  eye  is  more  easily  irrigated,  and  gradually  the  red- 
ness and  swelling  of  the  conjunctiva  disappears.  In  these  favorable  cases 
convalescence  is  established  within  two  or  three  weeks. 

In  the  gonococcus  cases  the  inflammation  is  much  more  violent,  the 
dangers  of  corneal  ulceration  greater,  and  the  disease  runs  a  more  pro- 
longed course  than  in  the  simple  cases  produced  by  other  pus-forming 
organisms. 

Diagnosis. — The  differential  diagnosis  of  gonorrheal  from  other  forms 
of  ophthalmia  is  made  by  the  history  of  the  case  with  reference  to  possible 
gonorrheal  infection  and  by  the  violence  of  the  inflammation.     In  doubt- 


96  DISEASES  OF  THE  NEW-BORX 

ful  cases  a  bacteriological  examination  may  determine  the  character  of  the 
infection. 

Prognosis. — Cases  that  are  seen  early  and  subjected  to  proper  treatment, 
as  a  rule,  terminate  in  complete  recovery.  Xeglected  cases,  especially  of 
the  gonococcus  type,  commonly  result  in  corneal  ulceration  with  permanent 
loss  of  vision. 

Prophylaxis. — The  prophylactic  treatment  is  especially  important'  in 
institutional  practice,  where  gonorrheal  and  other  forms  of  vaginitis  are 
so  commonly  seen  in  the  mother.  In  institutions,  therefore,  it  is  perliaps 
wise  to  employ  in  all  cases  the  preventive  treatment  recommended  by  Crede. 
Directly  after  birth  the  child  is  carefully  washed,  and  during  this  process 
special  care  should  be  taken  to  avoid  contaminating  the  conjunctiva  with 
the  bath  water  or  with  wash-rags  used  on  other  parts  of  the  infant's  body. 
Following  this,  one  drop  of  a  1  to  2  per  cent,  solution  of  nitrate  of  silver 
is  carefully  dropped  into  each  eye;  experience  favors  the  weaker  solution. 
In  private  practice  the  silver  solution  is  not,  as  a  rule,  indicated  unless 
the  mother  has  a  vaginal  discharge.  In  all  cases,  whether  in  institutional 
or  in  private  practice,  where  the  mother  has  a  purulent  or  other  vaginal 
discharge  the  vagina,  for  days  prior  to  the  delivery  of  the  child,  should  be 
carefully  douched  with  alkaline  antiseptics. 

In  private  practice  where  the  vaginal  conditions  in  the  mother  are 
normal  no  prophylactic  treatment  is  necessary  except  the  careful  washing 
of  the  infant's  eyes  with  a  weak  boric  acid  solution  immediately  after  de- 
livery. Where  one  eye  only  is  infected  it  is  of  the  greatest  importance  to 
protect  the  other  eye  from  inoculation.  This  perhaps  can  best  be  done  by 
covering  the  well  eye  with  cotton  and  lint  and  carefully  bandaging  it  so 
as  to  prevent  its  accidental  inoculation  with  the  pus  from  the  infected  eye. 
Such  a  bandage  should  be  removed  and  reapplied  daily,  to  see  that  the  eye 
has  not  become  infected. 

Treatment. — The  treatment  of  ophthalmia  neonatorum  is  of  such  great 
importance  that  to  carry  it  out  properly  requires  the  constant  attention, 
day  and  night,  of  capable  nurses,  and  where  the  inflammation  begins  vio- 
lently and  the  indications  are  that  the  disease  is  of  gonococcic  origin  it  is 
best  to  have  the  advice  of  an  oculist. 

The  treatment  consists  in  the  constant  application  of  ice-cold  com- 
presses. These  are  made  of  pieces  of  lint  or  gauze  large  enough  to  cover 
the  eye,  which  are  kept  on  a  piece  of  ice  floating  in  a  saturated  solution  of 
boric  acid  or  a  1  to  5,000  solution  of  bichlorid  of  mercury.  These  pieces  of 
cloth  are  transferred  from  the  ice  to  the  inflamed  eye  every  few  minutes 
and  changed  from  time  to  time  as  cleanliness  demands.  During  this  treat- 
ment, at  intervals  of  one  or  two  hours,  the  palpebral  fissure  should  be 
opened  and  the  pus  thoroughly  washed  out  of  the  eye  by  douching  it  with  a 
boracic  acid  solution,  and  once  in  twenty-four  hours  a  2  per  cent,  solution 
of  silver  nitrate  should  be  instilled  into  the  eye.  Within  a  few  days  the 
inflammation  should  begin  to  subside,  and  with  this  improvement  the  cold 
applications  may  be  applied  interruptedly  instead  of  continuously,  but  the 


CEPHALHEMATOMA  97 

irrigations  with  boric  acid  solution  and  the  instillations  of  silver  nitrate 
should  be  continued. 

If  the  cornea  is  involved  the  case  should  be  referred  to  an  oculist. 
In  these  cases  a  1  per  cent,  solution  of  atropin  should  be  dropped  into  the 
eye  from  time  to  time  until  the  iris  is  widely  dilated,  and  throughout  the 
treatment  this  dilatation  is  to  be  maintained.  In  these  corneal  cases  the 
irrigation  of  the  eye  with  mild  antiseptic  washes  and  the  use  of  silver  ni- 
trate solutions  as  above  noted  are  to  be  continued,  but  the  cold  applications 
are  of  doubtful  efficacy. 


CHAPTEK  IX 
BIETH   INJUEIES 

CEPHALHEMATOMA 

Symptomatology. — This  condition  is  due  to  an  injury  of  the  sub- 
periosteal blood  vessels  occurring  during  birth.  The  tearing  of  these  blood 
vessels  results  in  the  pouring  out  of  blood  between  the  bones  of  the  skull 
and  the  periosteum.  This  produces  a  swelling  of  the  scalp  which  commonly 
appears  between  the  first  and  the  fourth  day  of  life.  It  is  usually  located 
over  one  and  rarely  over  both  parietal  bones.  It  may  be  large  enough  to 
cover  the  whole,  but  in  most  instances  only  a  part,  of  the  parietal  bone, 
and  it  is  limited  by  the  parietal  sutures.  It  may  reach  the  size  of  a  large 
orange.  The  overlying  skin  undergoes  no  change  nor  is  there  any  tender- 
ness or  other  evidence  of  inflammatory  action.  The  tumor  is  soft  and 
fluctuating,  so  there  is  never  any  doubt  of  its  fluid  contents.  After  a  time, 
at  the  circumference  of  the  tumor,  a  hard,  distinct  elevation  forms.  The 
tumor  gradually  increases  in  size  for  a  period  of  perhaps  one  week;  there- 
after it  may  remain  stationary  for  a  few  days  and  then  very  gradually 
diminish  in  size.  It  commonly  requires  from  two  to  four  months  for  its 
complete  disappearance.  As  it  commences  to  diminish  in  size  it  loses  its 
tenseness  and  becomes  soft  and  flabby. 

Diagnosis. — The  differential  diagnosis  from  caput  succedaneum  should 
cause  no  embarrassment.  In  this  latter  condition  the  swelling  of  the  scalp 
is  not  only  present  but  is  at  its  height  at  birth.  It  does  not  fluctuate,  is 
soft  and  flabby  at  all  times,  and  begins  to  disappear  on  the  second  or  third 
day.  The  differential  diagnosis  from  hernia  of  the  brain  or  its  membranes 
presents  no  difficulties,  as  these  symptom  groups  are  quite  distinct.  From 
abscess  of  the  scalp  it  may  be  differentiated  by  the  absence  of  inflamma- 
tion. If  the  tumor  is  red  and  tender  and  accompanied  by  constitutional 
symptoms  the  introduction  under  aseptic  precautions  of  an  aspirating 
needle  will  determine  the  character  of  the  contained  fluid.  Earely  cephal- 
hematoma may  be  associated  with  a  hemorrhagic  diathesis  resulting  from 
some  severe  constitutional  disorder.  These  are  the  only  cases,  and  they 
are  very  rare,  in  which  the  prognosis  may  be  unfavorable. 


98  BIRTH    INJURIES 

Treatment. — As  a  rule  no  treatment  is  necessary;  spontaneous  recovery 
occurs.  If  there  be  delay  in  the  disappearance  of  the  tumor  it  may  be 
wise  to  inquire  whether  or  not  the  cephalhematoma  has  been  converted  by 
infection  into  an  abscess.  This  may  be  determined  by  the  introduction  of 
an  aspirating  needle.  In  the  event  that  pus  is  found  the  abscess  is  to  be 
evacuated  by  free  incision,  thoroughly  drained,  packed  with  gauze,  and 
thereafter  treated  as  any  other  abscess. 

HEMATOMA   OP   THE   STERNOCLEIDOMASTOID    MUSCLE 

This  condition  results  from  the  stretching  and  tearing  of  this  muscle  in 
such  a  way  as  to  produce  a  hemorrhage  into  its  sheath.  This  injury  is 
comparatively  rare,  but  occurs  most  commonly  in  breech  presentations. 

Symptomatology. — Soon  after  birth  it  is  noted  that  the  child  has  a  stiff 
neck.  Its  head  is  turned  to  the  affected  side.  This  torticollis  results  from 
contraction  of  the  injured  sternomastoid  muscle,  and  within  or  along  this 
tense  muscle  a  small  tumor  may  be  felt.  The  part  is  painful  to  touch  and 
the  child  cries  when  an  attempt  is  made  to  overcome  the  deformity.  After 
a  time  the  hematoma  is  absorbed,  but  the  contraction  of  the  muscle  may 
remain  for  many  months  and  in  some  cases  it  is  permanent. 

Treatment. — After  some  months,  when  all  soreness  and  tenderness 
have  disappeared,  an  attempt  should  be  made  to  overcome  the  deformity  by 
massage  and  passive  movements.  If  these  measures  fail  the  patient  should 
be  referred  to  an  orthopedic  surgeon,  that  the  deformity  may  be  overcome 
by  operative  measures. 

BIRTH   PALSIES 

Birth  palsies  may  be  central  or  peripheral  in  their  origin.  Central 
palsies  are  described  under  Cerebral  Palsies.  Peripheral  or  obstetrical 
palsies  occur  as  two  distinct  clinical  types,  known  as  facial  paralysis  and 
upper  arm  paralysis. 

FACIAL    PAEALYSIS 

This  is  a  paralysis  of  the  seventh  or  facial  nerve  produced  by  injury 
during  birth.  It  is  commonly  due  to  the  pressure  of  the  blades  of  the 
forceps.  In  most  instances  it  is  unilateral  and  the  diagnosis  is  made  by  a 
lack  of  symmetry  in  the  two  sides  of  the  face,  due  to  paralysis  of  the 
muscles  of  one  side.  This  is  much  more  noticeable  when  the  face  muscles 
are  in  action.  This  condition  is  of  little  pathological  importance,  as  the 
paralysis  disappears  spontaneously  in  two  or  three  weeks.  Very  rarely  the 
injury  to  the  nerve  may  be  so  great  that  a  permanent  paralysis  results. 

Treatment  as  a  rule  is  unnecessary.  In  those  cases,  however,  in  which 
the  paralysis  persists  the  muscles  should  be  exercised  and  atrophy  delayed 
or  prevented  by  the  systematic  use  of  massage  and  electricity  as  outlined 
under  Cerebral  Palsies. 


BIRTH   PALSIES  99 

UPPER   AEM   PARALYSIS 

(Duchenne-Erb's  Palsy) 

Etiology. — This  is  due  to  some  injury  of  the  fifth,  sixth,  and  seventh 
cervical  nerves  during  birth.  It  is  more  common  after  breech  presenta- 
tions. It  may  be  produced  by  pulling  or  twisting  the  arm  or  shoulder  or 
by  axillary  pressure  from  a  blunt  hook  or  the  obstetrician's  finger.  What- 
ever may  be  the  modus  operandi  of  the  development  of  this  paralysis,  the 
fifth  and  sixth  cervical  nerves  are  so  pressed  upon,  stretched,  or  twisted 
as  to  put  them  out  of  function,  and  a  motor  paralysis  of  the  muscles  which 
they  supply  results.  The  deltoid,  biceps,  brachialis  anticus,  and  supinator 
longus  muscles  are  most  commonly  involved.  * 

Symptomatology. — As  a  rule  only  one  arm  is  affected.  It  is  noticed 
within  two  or  three  days  after  birth  that  this  arm  hangs  limp  and  motion- 
less and  is  rotated  inward.  The  paralysis  in  these  cases  is  of  the  upper 
arm  type  described  by  Duchenne  and  Erb.  The  muscles  of  the  wrist  and 
hand  are  not  affected.  The  paralysis  is  almost  exclusively  motor;  there  is 
little  or  no  disturbance  of  sensation.  In  the  great  majority  of  cases  re- 
covery slowly  takes  place  within  two  or  three  months.  In  a  few  cases  the 
paralysis  persists,  the  affected  shoulder  droops,  muscular  atrophy  slowly 
takes  place,  and  after  a  time  the  shoulder  and  upper  arm  are  markedly 
lacking  in  development.  With  the  wasting  of  the  upper  arm  muscles  there 
is  also  more  or  less  lack  of  development  of  the  bones,  so  that  the  arm  is 
not  only  shriveled,  but  shorter  than  its  fellow  of  the  opposite  side.  Con- 
tractures of  the  muscles  of  the  lower  arm  and  hand  develop.  In  rare 
instances  subluxation  of  the  head  of  the  humerus  takes  place  and  greatly 
increases  the  deformity.  In  the  worst  cases  the  reaction  of  degeneration 
is  finally  followed  by  a  failure  to  respond  to  either  the  galvanic  or  faradie 
current  and  the  arm  remains  comparatively  useless  throughout  life. 

Treatment. — Within  two  or  three  weeks  after  birth  gentle  but  systematic 
massage  should  be  begun.  This  is  to  be  applied  especially  to  the  muscles  of 
the  shoulder  and  upper  arm.  If  at  the  end  of  the  third  month  conva- 
lescence has  not  been  established,  the  faradie  current  should  be  used  in 
connection  with  massage  to  exercise  the  paralyzed  muscles,  and  in  the 
event  that  the  muscles  do  not  respond  readily  or  normally  to  the  faradie 
current  the  galvanic  current  should  be  substituted.  This  treatment  should 
be  persisted  in  for  months,  and  in  the  event  contractures  occur  the  advice 
of  an  orthopedic  surgeon  should  be  sought.  Many  of  these  cases  are 
greatly  benefited  by  surgical  operations  and  by  orthopedic  appliances  to 
overcome  contractures  and  develop  weak  and  degenerating  muscles. 


SECTION   III 

INFANT  FEEDING 

■ 

CHAPTER  X 

MILK    IN    ITS    RELATION    TO    INFANTILE    NUTRITION 

Human  breast  milk  is  the  ideal  infant  food,  evolved  by  natural  laws  to 
suit  the  immature  digestive  organs  of  the  human  infant  and  to  furnish  the 
exact  nutritional  elements  necessary  for  the  rapid  growth  and  de^velopment 
of  the  human  organism.  Its  various  ingredients,  in  their  digestibility, 
their  chemical  composition,  their  total  quantity,  and  in  their  relative  pro- 
portion to  other  ingredients,  are  just  what  they  should  be;  and  if  it  were 
possible  to  feed  every  human  infant  upon  normal  human  milk  for  the  first 
nine  months  of  its  life  the  whole  problem  of  infant  feeding,  which  is  the 
most  important  single  subject  claiming  the  attention  of  pediatricians  to- 
day, would  dwindle  into  comparative  insignificance. 

Cow's  milk  is  also  an  ideal  food  for  the  young  of  its  kind,  and  its  vari- 
ous ingredients,  including  their  chemical  composition,  their  digestibility, 
their  quantity,  and  their  relative  proportion  to  other  ingredients,  are 
suited  to  the  purposes  cow's  milk  is  intended  to  serve;  namel3\  to  furnish 
nutrition  to  the  young  calf  and  to  develop  its  digestive  organs  so  as  to 
prepare  them  for  the  food  which  is  to  follow.  Thus  it  is  plainly  evident 
that  the  breast  milk  of  individual  mammals  is  suited  to  the  development 
of  the  young  of  its  kind,  but  is  not  necessarily  suited  and  has  not  been 
evolved  by  nature  to  nourish  and  develop  the  digestive  organs  of  a  different 
species. 

Milk  is  composed  of  fat,  protein,  carbohydrates,  mineral  salts,  water, 
ferments,  alexins,  antitoxins,  etc.  It  is  a  live  fluid  with  definite  chemical 
and  biological  properties  which  can  only  be  understood  by  a  careful  chemi- 
cal and  physiological  study  of  its  various  ingredients  in  relation  to  infantile 
nutrition. 

Fat. — The  fats  which  compose  about  4  per  cent,  of  both  human 
and  cow's  milk  are  found  in  fat  molecules  suspended  in  the  form  of  an 
emulsion.  Their  composition  is  very  complicated.  They  contain  neutral 
fats  and  fatty  acids.  The  larger  molecules  contain  a  greater  percentage 
of  volatile  fatty  acids  and  the  smaller  ones  more  oleic  acids,  so  that  in 

100 


FAT  101 

skimming  milk,  the  larger  fat  globules  rising  to  the  surface  above  the 
smaller  ones,  a  greater  percentage  of  volatile  fatty  acids  is  skimmed  oS. 
and  more  oleic  acid  left  in  the  small  globules.  These  fatty  acids  are 
mixed  with  glycerin  and  therefore  occur  in  the  form  of  glycerides.  Butyric, 
palmitic,  and  stearic  acids  are  the  most  important  of  the  fatty  acids.  A 
small  portion  of  the  fatty  acids  are  compounded  with  albumin  in  the  form 
of  lecithin,  which  may  exist  outside  of  the  fat  molecule.  Cow's  milk  eon- 
tains  a  greater  percentage  of  volatile  fatty  acids  and  a  less  percentage  of 
oleic  acid  than  human  milk,  and  the  fat  in  the  former  is  in  coarser  emulsion 
and  separates  more  easily  than  in  human  milk.  This  difference  in  the 
composition  of  the  fats  of  the  two  milks  may  in  part  explain  the  fact  that 
the  human  infant  may  digest  and  assimilate  4  per  cent,  of  fat  in  woman's 
milk  and  yet  fail  to  digest  2i/^  per  cent,  of  fat  in  cow's  milk,  and  it  may 
also  explain  why  cow's  milk,  with  its  excess  of  volatile  fatty  acids,  may 
predispose  to  acid  intoxications  in  infancy,  since  these  acids  may  be  readily 
converted  by  hydrolysis  into  diacetic  acid  and  acetone. 

In  the  natural  food  of  the  human  infant  fat  is  a  most  important  agent 
in  keeping  up  the  heat  and  furnishing  the  energy  for  cellular  work.  It  is 
the  fuel  of  the  cells  and  is  furnished  in  large  quantities  because  of  the 
unusual  cellular  activity  which  occurs  at  this  time  of  life.  It  is  the  most 
important  factor  in  increasing  the  weight  of  the  body  during  early  infancy 
and  is  stored  in  large  amounts  in  the  subcutaneous  tissues  to  serve  emer- 
gency purposes.  These  storehouses  are  drawn  upon  when  there  is  a  fail- 
ure in  fat  digestion  or  fat  assimilation.  The  nervous  system  which  is  so 
immature  at  birth  and  which  develops  so  rapidly  during  the  first  year  of 
life  demands  a  large  amount  of  fat  for  its  proper  development.  The  fat 
forms  an  important  element  of  nerve  structures,  and  there  is  no  part  of  the 
infantile  anatomy  which  suffers  more  seriously  or  more  profoundly  than 
does  the  nervous  system  when  the  digestion  and  assimilation  of  fats  is 
interfered  with.  The  bony  structures  also  depend  in  part  for  their  de- 
velopment upon  a  proper  amount  of  fat  in  the  tissues.  The  dangers  from 
too  liltle  fat  in  the  food  are  therefore  most  apparent,  resulting  in  lack  of 
development,  especially  in  nervous  and  bony  structures,  loss  of  weight, 
anemia,  and  malnutrition.  One  should  also  remember  that  an  excess  of  fat 
in  the  food  of  the  infant  may  produce  constipation  or  diarrhea  with  fat- 
stools  and  more  or  less  serious  gastrointestinal  and  nutritional  disturbances ; 
the  serious  "food  injuries"  which  result  from  an  excess  of  fat  are  very 
uncommon  except  in  those  cases  where  both  the  fats  and  the  sugars  are 
given  in  excess  at  the  same  time.  When  the  sugar  percentage  of  a  food  is 
high  an  excess  of  fats  is  likely  to  cause  more  or  less  serious  digestive  disturb- 
ance and  vice  versa.  It  is,  therefore,  sometimes  difficult  to  tell  whether  the 
child  has  been  made  ill  by  the  fats  or  the  sugars,  since,  as  a  rule,  improve- 
ment follows  the  elimination  of  either  the  fats  or  sugars  from  the  diet. 

Protein. — The  chief  proteins  of  milk  are  casein  atid  lactalbumin ;  lacto- 
globulin,  lactoprotein,  and  nuclein  occur  in  smaller  quantities.  Under  the 
term  whey  proteins  all  the  proteins  of  milk  except  casein  are  grouped.    In 


102        MILK  IN  RELATION  TO  INFANTILE  NUTRITION 

woman's  milk  the  whey  proteins  predominate  over  the  casein  in  the  pro- 
portion of  2  to  1,  but  in  cow's  milk  the  proportion  is  as  1  to  6.  Chemistry 
has  not  as  yet  made  any  practical  or  important  differentiation  between  the 
whey  proteins  of  woman's  and  cow's  milk,  but  we  have  in  the  quantities  of 
casein  and  soluble  albumins  they  contain  two  entirely  different  milks.  The 
most  important  difference  lies  perhaps  in  the  chemistry  of  the  two  caseins. 
This  difference  is  recognized  by  the  manner  in  which  they  react  to  the 
same  ferments  and  reagents.  In  the  stomach  of  the  human  infant  the 
calcium  casein  of  cow's  milk  (the  form  in  which  casein  exists  in  cow's  milk) 
is  readily  precipitated  by  rennet,  in  the  presence  of  a  slight  amount  of 
acid,  into  a  clot  of  calcium  paracasein,  and  later,  as  the  hydrochloric  acid 
is  secreted  in  larger  quantities,  into  hydrochlorate  of  paracasein  and  cal- 
cium ;  the  calcium  being  separated  from  the  paracasein  clot  by  the  hydro- 
chloric acid.  This  clot  is  larger  and  tougher  than  the  clots  which  occur 
in  the  infant  stomach  from  the  action  of  the  same  reagents  on  human  milk. 
In  human  milk  the  paracasein  clots  and  the  hydrochlorate  of  paracasein 
clots  are  soft  and  light  as  compared  with  those  of  cow's  milk. 

Casein  is  rarely  the  cause  of  intestinal  disturbance.  On  the  other  hand, 
Finkelstein  and  Meyer  have  apparently  demonstrated  that  intestinal  indi- 
gestion may  be  improved  or  controlled  by  increasing  the  quantity  of  the 
casein  and  diminishing  the  quantity  of  the  sugar  or  fat  in  the  milk. 
The  digestibility  of  the  casein  of  cow's  milk  depends  largely  upon  the 
presence  or  absence  of  the  conditions  in  the  infantile  stomach  which  cause 
its  precipitation  in  small  or  large  curds.  It  is  very  easily  digested  and 
assimilated  if  large  clot  formations  can  he  prevented.  If  an  alkali  such  as 
lime  water  or  sodium  bicarbonate,  or  an  acid  such  as  hydrochloric  or  lactic, 
be  added  to  cow's  milk  before  it  enters  the  stomach,  the  alkali  on  the  one 
hand  or  the  acid  on  the  other,  by  combining  with  the  casein,  may  interfere 
with  the  action  of  the  rennet  in  the  formation  of  large  clots,  since  rennet 
can  only  act  in  a  slightly  acid  medium.  The  boiling  of  milk  will  also  pre- 
vent the  formation  of  large  casein  clots.  In  some  instances  it  may  also  be 
necessary  to  reduce  temporarily  the  amount  of  fat  in  the  milk,  so  as  to 
prevent  its  entanglement  in  the  meshes  of  the  clot.  The  danger,  therefore, 
from  an  excess  of  protein  lies  in  the  fact  that  we  are  not  always  able  to 
control  the  factors  which  cause  clot  formation,  and  for  this  reason  it  is 
sometimes  necessary  to  diminish  the  amount  of  protein  to  a  point  where 
clot  formation  will  not  interfere  with  the  intestinal  digestion  of  the  casein. 
In  such  instances  it  may  be  necessary"  to  substitute  the  whey  proteins  in 
part  for  the  casein  so  that  the  protein  content  of  the  food  may  not  fall 
below  the  absolute  nutritional  demands  of  the  body.  In  doing  this,  however, 
it  should  be  remembered  that  in  infants  suffering  from  digestive  disturb- 
ances the  whey  of  cow's  milk  may  aggravate  the  trouble.  The  human  in- 
fant may  digest  the  various  food  elements  of  cow's  milk  when  they  are  held 
in  the  whey  of  humail  milk  and  may  fail  to  digest  them  in  the  whey  of 
cow's  milk. 

The  casein  of  cow's  milk  contains  53  per  cent,  of  carbon,  15.65  per  cent. 


CARBOHYDEATES  103 

of  nitrogen,  7.06  per  cent,  of  hydrogen  and  0.85  per  cent,  of  phosphorus, 
and  0.78  per  cent,  of  sulphur.  The  general  composition  of  proteins  with 
the  large  per  cent,  of  nitrogen  they  contain  makes  them  absolutely  neces- 
sary for  cell  growth  and  cell  life.  They  furnish  the  material  in  large  part 
from  which  the  cells  of  the  body  are  built  up,  and  Avith  the  continuous 
cellular  activity  and  nitrogenous  waste  there  is  a  demand  in  the  rapidly 
growing  body  of  the  infant  for  sufficient  protein  in  the  food  not  only  to 
supply  the  cell  waste,  but  to  furnish  material  for  the  growth  of  new  cells. 
The  fats  and  carbohydrates,  furnishing,  as  they  do,  the  fuel  from  which  the 
cells  manufacture  the  heat  and  energy  of  the  body,  are  necessary  to  prevent 
excessive  nitrogenous  waste,  since  the  proteins  are  burnt  up  by  the  cells 
when  the  fats  and  carbohydrates  are  not  present  in  sufficient  quantity  to 
supply  them  with  fuel.  This  protection  of  the  proteins  by  the  fats  and 
carbohydrates  enables  the  cells  to  get  on  with  the  minimum  amount  of 
protein,  a  quantity  sufficient  to  supply  the  normal  nitrogenous  waste  and 
the  material  for  new  cells.  The  great  loss  that  is  sustained  in  protein  food 
in  the  absence  of  fats  and  carbohydrates  is  indicated  by  the  fact  that  twenty- 
two  parts  of  protein  are  equal  in  fuel  value  to  only  ten  parts  of  fat.  It 
is  very  evident,  therefore,  that  an  artificial  food  should  be  carefully  ad- 
justed in  its  various  ingredients  to  furnish  the  cells  with  sufficient  energy 
and  heat-producing  food  so  that  the  proteins  may  not  be  wasted  in  serving 
this  purpose.  If  the  food  of  the  infant  should  contain  too  little  protein 
or  if  the  fats  and  carbohydrates  are  diminished  to  such  a  low  percentage 
that  a  portion  of  the  moderate  amount  of  protein  taken  be  used  for  fuel, 
in  both  instances  we  would  have  a  protein  starvation,  resulting  in  anemia, 
malnutrition,  and  general  enfeeblement  of  cellular  activity  in  all  parts  of 
the  body. 

Carbohydrates. — Human  milk  contains  nearly  7  per  cent,  and  cow's 
milk  about  4  per  cent,  of  milk  sugar.  This  is  the  only  carbohydrate  that 
has  been  found  in  milk.  There  is  little  variation  from  day  to  day  in  the 
quantity  of  sugar  in  either  woman's  or  cow's  milk,  this  ingredient  being 
subject  to  much  less  variation  in  quantity  than  the  fats  and  proteins. 
Chemistry  has  not  demonstrated  any  important  difference  in  the  compo- 
sition or  reaction  to  digestive  ferments  of  the  sugar  found  in  the  milk  of 
different  mammals.  The  milk  sugar  in  human  milk  is  especially  adapted 
to  supply  carbohydrate  food  to  the  young  infant.  It  does  not  readily  fer- 
ment and  is  quickly  converted  into  dextrose  in  the  intestines.  On  the  other 
hand,  the  milk  sugar  of  cow's  milk  is,  according  to  the  German  school, 
the  most  common  cause  of  intestinal  fermentation.  It  appears  that  milk 
sugar,  when  held  in  the  whey  of  cow's  milk,  is  less  rapidly  absorbed  and 
more  subject  to  fermentation  than  is  maltose  or  dextrin.  The  great  ma- 
jority of  normal  infants,  however,  can  readily  digest  it. 

The  carbohydrates  next  to  the  albumins  are  the  most  important  food  of 
the  infant.  They,  like  the  fats,  serve  as  a  fuel  for  the  cells  making  heat, 
and,  what  is  more  important,  furnish  the  food  which  supplies  energy 
to  the  cells.     In  their  heat-forming  capacity  they  are  second  to  the  fats 


104        MILK  IN  RELATION  TO  INFANTILE  NUTRITION 

and  in  their  energy-furnishing  power  they  take  the  lead.  It  is  an  important 
physiological  fact  that  the  oxygen  contained  in  carbohydrates  is  not  only 
sufficient  to  oxidize  their  own  hydrogen  but  to  materially  aid  in  oxidizing 
the  waste  products  of  the  fat  and  protein  molecules  as  they  are  broken  down 
in  the  body,  thus  preventing  an  autointoxication.  This  is  but  an- 
other example  of  the  interdependence  of  the  protein,  fat  and  carbohy- 
drate molecules  in  serving  the  nutritional  demands  of  the  body,  and 
makes  plain  the  fact  that  we  are  acting  wisely  when  we  imitate  nature 
in-  making  an  infant  food  by  combining  these  food  elements  in  proper 
proportions. 

An  excess  of  carbohydrates  with  other  food  elements  (especially  the 
fats)  in  normal  proportions  may  result  in  diarrhea,  loss  of  weight,  fever,  in- 
testinal irritation,  and  catarrh.  An  excess  of  carbohydrates  with  the  other 
food  elements  below  normal  may  result  in  anemia,  rickets,  and  general 
malnutrition.  A  deficiency  in  carbohydrates  with  other  food  elements  in 
excess  will,  as  a  rule,  overtax  the  digestive  capacity  of  the  infant  and 
thereby  produce  digestive  disturbances. 

Inorganic  Constituents  of  Milk. — Calcium,  sodium,  potassium,  magne- 
sium, phosphorus  and  iron  are  the  most  important  inorganic  constituents  of 
milk.  All  of  these,  excepting  iron,  are  present  in  both  human  and  cow's 
milk  in  sufficient  quantities  to  meet  the  nutritional  demands  of  the  growing 
infant. 

Iron,  as  a  necessary  constituent  of  hemoglobin,  is  all-important  in  the 
oxidation  processes  which  underlie  body  metabolism.  The  deficiency  of 
iron  in  milk,  which  gradually  increases  as  lactation  proceeds,  is  made  up 
during  the  first  year  of  life  from  the  stores  of  this  mineral  found  in  the 
liver  and  other  organs  of  the  newly  born  infant.  At  birth  there  is  three 
times  as  much  iron  in  proportion  to  body  weight  as  in  the  adult.  The 
partial  iron  starvation  which  occurs  on  a  milk  diet  is  not  therefore  of 
material  consequence  during  the  first  year  of  life.  But  as  the  storehouses  of 
iron  become  exhausted  it  is  necessary  to  supplement  the  milk  diet  by  such 
iron  containing  foods  as  eggs,  fruit,  and  purees  of  vegetables,  otherwise 
anemia  and  serious  malnutrition  may  result. 

The  other  inorganic  constituents  of  milk  play  a  no  less  important  role 
m  the  body  metabolism  of  the  human  infant  than  does  iron.  All  of  these 
are  found  in  such  organic  combinations  in  human  milk  that  they  are  readily 
assimilated  in  sufficient  quantities  to  meet  nutritional  demands.  It  is  also 
true  that  the  normal  human  infant  can,  as  a  rule,  assimilate  sufficient  quan- 
tities of  the  inorganic  constituents  of  cow's  milk.  The  fact  that  a  smaller 
percentage  of  the  salts  of  cow's  milk  is  assimilated  is  offset  by  the  fact  that 
they  occur  in  larger  quantities  in  cow's  milk  than  in  human  milk.  In  cer- 
tain pathological  conditions,  however,  the  failure  of  the  human  infant  to 
assimilate  the  salts  of  cow's  milk  produces  serious  disorders  of  nutrition 
and  thereby  becomes  a  factor  in  the  production  of  marasmus  and  infantile 
atrophy.  The  common  practice  of  adding  lime  water,  sodium  chlorid  and 
other  alkaline  salts  to  cow's  milk  not  only  promotes  the  digestion  and 


WATER  105 

absorption  of  casein,  but  also  facilitates  the  absorption  of  its  mineral  salts, 
especially  calcium. 

The  uses  of  mineral  salts  in  the  body  are  manifold.  They  are  necessary 
for  the  growth  and  functional  activity  of  all  its  cellular  elements.  They 
enter  very  largely  into  the  construction  of  the  bony  framework  which  is 
growing  so  rapidly  during  the  first  year  of  life ;  for  this  purpose  large  quan- 
tities of  calcium  and  phosphorus  are  especially  necessary.  They  maintain 
the  normal  irritability  of  nerve  and  muscle  elements;  in  this  function 
calcium  plays  the  most  important  physiological  role.  A  partial  calcium  and 
phosphorus  starvation  produces  not  only  abnormalities  in  the  bony  frame- 
work, but  greatly  exaggerated  irritability  of  nerves  and  muscles.  The 
causes  that  lead  to  calcium  starvation,  however,  are  not  always  to  be  found 
in  the  food,  since  MacCallum  and  others  have  shown  tliat  a  diminished 
secretion  of  the  parathyroid  glands  may  be  a  factor  in  its  production.  The 
mineral  salts  also  maintain  the  osmotic  pressure  which  determines  the  flow 
of  water  to  and  from  the  fixed  tissue  cells  producing  a  shrinking  of  the 
tissues  on  the  one  hand  or  a  swelling  (edema)  on  the  other.  They  also 
regulate  the  acidity  or  alkalinity  of  the  body  fluids,  a  most  important  func- 
tion, since  upon  the  carefully  adjusted  reaction  of  the  blood  and  other  body 
media  depends  the  normal  functional  activity  of  every  cellular  element 
in  the  body. 

The  mineral  salts  and  their  combinations  are  an  essential  part  of  the 
food  of  the  infant.  They  must  be  presented  not  only  in  proper  relative 
proportions,  but  in  such  a  form  that  they  can  be  readily  assimilated.  These 
objects  cannot  be  accomplished  during  the  early  months  of  life  in  any  other 
way  except  by  the  feeding  of  milk,  preferably  human  milk  whose  saline 
constituents  are  held  in  such  organic  combinations  that  they  are  readily 
assimilated. 

From  the  foregoing  outline  it  is  evident  that  all  the  food  ingredients 
of  milk  are  absolutely  necessary  to  the  health  of  the  infant,  and  it  is  futile, 
therefore,  to  further  discuss  their  relative  importance.  The  normal  infant 
has  storehouses  of  protein,  fat,  carbohydrates,  and  salts  always  at  hand, 
and  has  also  a  protective  mechanism  which  enables  it  to  substitute  other 
materials  for  a  time  in  case  there  be  a  partial  starvation  in  any  one  of 
these  food  elements.  But  these  storehouses  may  in  time  be  exhausted  and 
these  protective  mechanisms  may  fail,  and  then  comes  disaster  to  the  infant 
in  the  form  of  some  severe  malnutrition,  it  matters  not  in  which  of  the  food 
elements  there  be  a  famine. 

"Water. — About  68  per  cent,  of  the  infant's  body  is  composed  of  water 
and  about  87  per  cent,  of  its  natural  food  (milk)  is  water.  These  facts 
indicate  the  important  role  that  water  plays  in  the  physiological  processes 
necessary  to  maintain  the  health  and  life  of  the  infant.  An  infant  re- 
quires four  or  five  times  as  much  water  in  proportion  to  body  weight  as 
an  adult. 

Water  is  the  great  solvent  which  brings  into  solution  or  suspension  the 
food  of  the  infant  so  as  to  present  that  food   (the  proteins,  the  carbohy- 


106        MILK  IN  RELATION  TO  INFANTILE  NUTRITION 

drates,  the  fats,  and  the  salts)  in  such  a  form  that  it  can  be  readily  cared 
for  by  the  digestive  organs.  It  carries  the  digested  and  assimilated  food 
through  the  blood  and  lymph  channels  to  every  part  of  the  body.  This 
common  carrier  makes  up  about  78  per  cent,  of  the  blood  and  96  per  cent, 
of  the  lymph,  and  becomes  the  circulating  media  of  the  body,  carrying  the 
important  elements  of  the  blood  and  lymph  to  every  cell  in  the  body  and 
carrying  away  from  the  cells  to  be  excreted  the  waste  materials  of  retro- 
grade tissue  metamorphosis.  This  excretion  of  body  waste  prevents  auto- 
intoxication and  is  effected  by  the  elimination  of  the  water  carrying  this 
waste  through  the  kidneys,  the  intestines,  the  skin,  and  the  lungs.  The 
discharge  through  all  these  avenues  of  excretion  is  much  more  active  in 
infancy  than  later  in  life ;  this  is  especially  true  of  the  more  active  elimina- 
tion through  the  skin  of  the  infant,  which  is  fourfold  greater  than  in  the 
adult.  Martin  H.  Fischer  has  emphasized  the  fact  that  water  is  practically 
the  only  diuretic  and  diaphoretic  we  have;  all  other  agents  supposed  to 
act  in  these  ways  do  so  indirectly  by  bringing  to  the  kidneys  or  skin  free 
water  ready  for  excretion. 

In  the  emergencies  which  disease  produces  nature  takes  advantage  of 
these  various  channels  for  the  rapid  elimination  of  waste  materials,  and 
enormous  quantities  of  poisonous  fluids  are  carried  off  in  a  short  time, 
especially  through  the  skin  and  bowels.  In  these  same  emergencies  the 
physician  attempts  to  replenish  the  body  fluids  of  the  infant  with  pure 
water  or  physiological  salt  solution,  so  that  vital  processes  may  not  suffer 
from  the  partial  water  famine  which  nature  has  created  in  her  strenuous 
efforts  to  save  the  life  of  the  child.  Thus,  in  certain  of  these  emergencies, 
water  becomes  a  life-saver  more  important  than  food,  stimulants,  and  all 
other  agents.  In  the  artificial  feeding  of  infants  an  excess  of  water  is  not 
infrequently  given.  An  infant  should  not  be  given  more  fluid  than  a 
breast-fed  baby  of  the  same  age  would  obtain  from  its  mother  under  normal 
conditions.  Too  much  water  in  the  food  may  cause  dilatation  of  the  stom- 
ach, indigestion,  and  consequent  malnutrition. 

Digestive  Ferments. — Human  milk  contains  a  diastatic  ferment  which 
transforms  starch  into  maltose  and  dextrose.  Becamp  was  the  first  to 
find  this  ferment;  it  has  since  been  demonstrated  by  a  number  of  ob- 
servers, and  according  to  Spolverini  may  be  developed  in  the  milk  of  the 
cow  and  goat  by  feeding  them  on  germinating  barley.  This  would  in- 
dicate that  there  is  an  important  physiological  purpose  served  by  this  fer- 
ment in  the  young  human  infant  which  is  met  in  some  other  way  in  the 
young  of  the  cow  and  the  goat.  The  purpose  served  is  perhaps  to  supple- 
ment the  feeble  digestive  power  for  starch  in  the  young  human  infant,  and 
as  the  starch  digestive  capacity  of  the  young  of  the  cow  and  goat  is  greater 
it  is  not  necessary  to  provide  this  ferment  in  their  milk. 

Lipase  is  a  fat-splitting  ferment  which  breaks  down  neutral  fats  into 
fatty  acids  and  glycerin.  It  was  isolated  by  Lussatti  and  Biolchini  and  is 
much  more  active  in  human  than  in  cow's  milk.  This  active  fat-splitting 
ferment  in  human  milk  may  account  in  part  for  the  fact  that  young 


ALEXINS  107 

infants  are  capable  of  digesting  and  assimilating  much  larger  quantities 
of  the  fat  of  human  milk  than  of  cow's  milk. 

Arguing  by  analogy,  one  would  think  that  nature,  in  developing  a  fat- 
splitting  and  a  starch-digesting  ferment  in  woman's  milk,  would  also  have 
developed  a  protein-digesting  ferment,  and  this  is  very  probably  the  case, 
although  experimental  evidence  is  not  as  yet  sufficient  to  put  this  question 
beyond  a  doubt.  Spolverini  demonstrated  the  action  of  ferments  which 
resembled  the  action  of  trypsin  and  pepsin,  but  Benoit  could  not  agree  with 
him. 

Alexins. — Alexins  are  substances  which  have  a  bactericidal  and  globuli- 
cidal  action.  They  are  found  in  human  milk  in  sufficient  quantities  to 
make  it  decidedly  destructive  to  bacteria  and  other  foreign  cells.  They 
are  perhaps  derived  in  part  from  both  the  serum  of  the  blood  and  from 
the  cells  of  the  mammary  gland.  This  property  of  human  milk  is  perhaps 
one  of  the  most  important  safeguards  which  the  young  breast-fed  infant 
has  against  gastrointestinal  diseases.  The  microorganisms,  which  are  con- 
stantly being  put  into  their  mouths,  on  foreign  objects,  rarely  produce  any 
serious  intestinal  disturbance.  It  is  also  true  that  artificially  fed  infants 
when  suffering  from  gastroenteritis  will,  as  a  rule,  quickly  recover  when 
given  breast  milk,  and  it  is  probable  that  the  bactericidal  action  of  the 
milk  is  one  of  the  factors  that  contributes  to  this  result.  The  alexins 
are  not  absorbed  in  sufficient  quantities  from  the  milk  to  give  to  the  blood 
and  other  body  fluids  of  the  infant  any  marked  bactericidal  qualities,  so 
that  the  comparative  immunity  which  breast-fed  infants  enjoy  from  certain 
acute  infectious  diseases  is  perhaps  due  to  other  substances,  which  pass 
from  the  mother  through  the  breast  milk  to  the  infant,  such  as  antitoxins, 
agglutinins,  and  other  antibodies.  The  immunity,  either  natural  or  ac- 
quired, W'hich  the  mother  or  wet  nurse  has  for  certain  infectious  diseases 
is,  in  part  at  least,  transferred  to  the  nursing  infant.  The  substances  which 
confer  that  immunity  are  transferred  through  the  milk  to  the  infant.  It 
follows  therefore  that  the  nursing  infants  are  partially  immune  from  those 
infections  only  to  which  their  wet  nurse  is  immune. 


CHAPTEE  XI 

HUMAN    BREAST    MILK    IN    ITS    RELATIONS    TO    INFANT    FEEDING 

COMPOSITION  OF  COLOSTRUM  AND  HUMAN  MILK 

Colostrum  is  the  secretion  of  the  human  breasts  which  immediately 
precedes  the  formation  of  breast  milk.  About  the  fourth  month  of  preg- 
nancy the  breasts  commence  to  secrete  in  scanty  amounts  a  yellowish, 
sticky  fluid  called  colostrum.  This  secretion,  which  can  be  squeezed  out 
of  the  breasts  in  slightly  increasing  quantities  from  this  time  until  the 
birth  of  the  child,  is  present  in  sufficient  quantities  during  the  first  few 
davs  after  birth  to  act  as  a  laxative  and  serve  nutritional  purposes. 


108       MILK   IX   ITS  KELATIOXS   TO   INFANT   FEEDING 

Colostrum  differs  from  normal  milk  in  its  physical  and  chemical  prop- 
erties. It  is  more  alkaline  in  reaction,  more  yellow  in  color,  is  not  so  sweet, 
and  has  a  higher  specific  gravity,  1.040.  It  is  richer  in  fat  and  soluble 
proteins  and  poorer  in  casein.  Under  the  microscope  it  shows  peculiar 
large  characteristic  corpuscles  which  are  filled  with  fat  globules  of  varying 
sizes.  On  the  removal  of  this  fat  by  ether  the  corpuscle  shows  a  large 
nucleus.  These  corpuscles  are  from  five  to  ten  times  the  size  of  the  human 
blood  corpuscle.  Leukocytes  and  pavement  epithelium  are  also  present  in 
addition  to  a  large  number  of  fat  globules  similar  in  size  to  those  found 
in  normal  human  milk.  The  composition  of  colostrum  is  shown  in  the 
following  table  from  Camerer  and  Soldner : 

Water     86. 70 

Proteins    3.07 

Fat    3.34 

Milk  sugar 5.27 

Ash    0.40 

Under  the  stimulus  of  nursing  the  colostrum  gradually  gives  way  to 
the  normal  milk  secretion,  which  may  be  established  as  early  as  the  third 
day,  but  is  sometimes  more  or  less  delayed  until  the  fifth  or  sixth  day. 


Fig.  17. — Colostrxjm. 


Fig.  18. — Woman's  Milk. 


Human  milk  is  a  bluish  white,  sweet  fluid  which,  as  shown  by  Kerley 
and  others,  is  faintly  acid  to  phenolphthalein,  but  is  amphoteric  or  neutral 
to  litmus  paper.  Its  specific  gravity  varies  from  1.027  to  1.035.  Micro- 
scopically the  fat  globules,  which  vary  in  size  from  that  of  a  red  to  a 
white  blood  corpuscle,  are  held  in  more  or  less  satisfactory  emulsion. 
Epithelial  cells,  colostrum  and  pus  corpuscles  which  are  occasionally  found 
are  to  be  regarded  as  foreign  elements  and  as  indications  pointing  to  the 
deterioration  or  contamination  of  the  milk. 


HOW    TO    DETERMINE    WHOLESOMENESS    OF    MILK   109 


HOW  TO  DETERMINE  THE  WHOLESOMENESS  OF  MILK 

The  fundamental  characteristics  which  differentiate  the  milk  of  differ- 
ent species  were  dwelt  upon  in  tlie  previous  chapter,  and  in  these  important 
facts  we  learn  why  it  is  so  necessary  to  the  nutritional  demands  of  the 
infant  that  it  should  have  all  the  breast  milk  it  can  possibly  get  under  the 
existing  circumstances.  This  principle  in  infant  feeding  is  all-important 
since  about  two-thirds  of  the  mothers  of  our  land  are  unable  to  furnish 
their  infants  with  a  milk,  which  in  quantity  and  quality  is  equal  to  the 
nutritional  demands  of  the  first  nine  months  of  life.  Among  the  wealthy 
class  it  is  rather  unusual  to  find  a  mother  who  can  supply  breast  milk  to 
meet  the  demands  of  her  infant.  Among  the  poor  the  woman  has  to  work 
the  greater  portion  of  the  day  in  unhygienic  surroundings,  live  on  improper 
and  perhaps  insufficient  food  and  be  separated  from  her  infant  many  hours 
at  a  time,  which  interferes  with  her  furnishing  normal  milk  at  proper 
intervals  throughout  the  full  period  of  lactation.  It  is  largely,  therefore, 
among  the  middle  class  that  we  find  women  who  are  not  only  willing  but 
who  are  physically  able  to  fully  nourish  their  infants  for  a  proper  length 
of  time.  In  America,  perhaps  more  than  in  other  countries,  the  social 
conditions  are  unfavorable  to  the  production  of  mothers  capable  of  per- 
forming this  most  important  function.  At  any  rate,  we  are  led  to  infer 
from  published  observations  that  supplemental  and  full  artificial  feeding 
are  perhaps  more  commonly  necessary  in  this  country  than  in  some  Euro- 
pean countries. 

In  approaching  the  subject  of  breast-feeding  it  is  important  that  the 
physician  should  understand  that  there  are  ofttimes  abnormal  variations  in 
the  quantity  and  composition  of  an  otherwise  good  milk,  which  may  make  it 
temporarily  insufficient  or  unwholesome  for  the  infant.  It  is  plainly  evident 
therefore  that  it  would  be  worse  than  folly  for  the  physician  to  infer  that 
such  a  milk  was  not  suited  to  the  nutritional  demands  of  the  individual 
infant  until  a  more  or  less  prolonged  trial  of  the  milk,  its  chemical  compo- 
sition or  the  conditions  under  which  it  is  produced  have  demonstrated  that 
it  is  an  unsuitable  food.  The  physician  should  have  in  mind  certain  facts 
which  will  help  him  in  determining  the  wholesomeness  of  an  individual 
breast  milk  in  its  relation  to  the  nutritional  demands  of  an  individual 
infant,  and  along  these  lines  the  following  observations  are  important : 

1.  If  a  breast-fed  baby  is  well  nourished  and  gaining  in  weight,  all 
indications  pointing  to  the  unwholesomeness  of  its  food,  such  as  colic  and 
indigestion,  are  of  minor  importance  and  suggest  not  that  the  breast  milk 
be  discontinued,  but  that  it  be  modified  by  regulating  the  diet  and  general 
hygiene  of  the  mother. 

2.  If  a  breast-fed  baby  is  poorly  nourished  and  losing  in  weight,  with 
no  evidence  on  the  part  of  the  infant  that  the  milk  is  producing  gastro- 
intestinal disturbance,  the  indications  are  not  that  the  breast  milk  should 
be  discontinued,  but  that  it  be  supplemented  by  artificial  feeding  at  each 


110      MILK  IN   ITS  EELATIOXS  TO   INFANT   FEEDING 

nursing  and  an  effort  made  to  increase  the  quantity  and  (juality  of  the 
mother's  milk  by  proper  food  and  hygiene. 

3.  A  poorly  nourished  breast-fed  baby,  losing  in  weight  and  suffering 
from  chronic  indigestion  both  on  breast  and  mixed  feedings,  should  be 
weaned  or  provided  with  another  wet  nurse.  In  these  comparatively  rare 
cases  the  individual  breast  milk  is  at  fault  even  though  chemistry  may  fail 
to  find  the  defect. 

If  the  question  arises  as  to  whether  a  mother's  milk  is  a  suitable  food 
for  the  infant,  the  infant  itself  under  the  three  fundamental  rules  above 
given  is  the  best  answer  to  this  question.  As  supplemental  evidence,  how- 
ever, an  examination  of  the  breast  milk  may  be  made  to  determine  its  quan- 
tity and  also  the  relative  and  absolute  quantity  of  its  various  ingredients. 
The  quantity  of  the  breast  milk  may  be  determined  by  weighing  the  baby 
before  and  after  each  nursing,  and  for  practical  purposes  it  may  be  assumed 
that  an  increase  of  an  ounce  in  weight  indicates  that  a  fluid  ounce  of  milk 
has  been  taken;  that  is  to  say,  if  the  infant  weighs  five  ounces  more  after 
a  nursing  it  has  taken  five  fluid  ounces  of  milk;  and  it  may  also  be  as- 
sumed, for  practical  purposes,  that  infants  between  one  and  seven  months 
of  age  should  take  in  the  average  at  each  nursing  one  ounce  more  than 
they  are  months  old.  Holt  gives  the  following  table  of  the  daily  average 
quantity  of  milk  taken  by  normal  infants  at  different  ages : 

At  the  end  of  the  1st  week 10  to  16  oz.  (300  to     500  gm.) 

During  the  2d  week 13  to  18  oz.  (400  to     550  gm.) 

During  the  3d  week 14  to  24  oz.  (430  to     720  gm.) 

During  the  4th  week 16  to  26  oz.  (500  to     800  gm.) 

From  the  5th  to  the  13th  week 20  to  34  oz.  (600  to  1,030  gm.) 

From  the  4th  to  the  6th  month 24  to  38  oz.  (720  to  1,150  gm.) 

From  the  6th  to  the  9th  month 30  to  40  ta.  (900  to  1,200  gm.) 

The  quality  of  the  milk  with  reference  to  the  amount  of  its  various 
ingredients  may  be  determined  by  a  chemical  analysis,  but  as  the  variations, 
especially  in  the  fats  and  proteins,  from  day  to  day  are  very  marked,  it  is 
generally  necessary  to  make  repeated  examinations  of  the  milk  to  arrive 
at  its  average  composition.  Milk  analyses,  therefore,  because  of  their  un- 
reliability and  the  expense  of  making  them,  are  not  of  sufficient  practical 
value  to  warrant  their  use  as  a  routine  measure.  In  a  breast-fed  baby, 
suffering  from  well-marked  scurvy,  a  professional  chemist  reported  to  me 
that  the  breast  milk  was  absolutely  normal.  A  change,  however,  to  cow's 
milk  in  this  case  brought  about  a  rapid  cure.  Simpler  and  less  accurate 
methods  for  examining  breast  milk  are  used  and  the  approximate  results 
thus  obtained  may  be  of  some  value.  For  this  purpose  the  physician  may 
use  Holt's  apparatus,  made  by  Eimer  &  Amend,  of  New  York.  Full 
directions  for  its  use  accompany  each  set  of  apparatus. 

Holt  gives  the  following  table  as  the  average  composition  of  human 
breast  milk: 


HOW    TO    MODIFY    QUANTITY    AND    QUALITY    OF  MILK  111 

Average  Common  Healthy 

per  cent.  variations  per  cent. 

Fat     4.00  3.00  to  5.00 

Sugar     7.00  6.00  to  7.00 

Proteins    1.50  1.00  to  2.25 

Salts     0.20  0.18  to  0.25 

Water    87.30  89.82  to  85. 50' 


100.00  100.00         100.00 

The  sample  of  milk  used  for  analysis  should  be  a  part  of  all  the  milk 
that  can  be  taken  from  the  breast.  The  physiological  stimulus  of  sucking 
is  not  given  by  the  breast  pump,  and  the  milk  drawn  in  this  way  is  there- 
fore usually  low  in  fat  and  protein.  The  usual  examination  of  breast  milk 
made  from  small  samples  drawn  by  the  pump  are  misleading  because  they 
do  not  represent  the  same  quality  of  milk  which  the  infant  receives  from 
the  breast. 

HOW  TO  MODIFY  THE  QUANTITY  AND  QUALITY  OF  MILK 

In  modifying  human  milk  to  suit  the  nutritional  demands  and  diges- 
tive capacity  of  the  infant  it  is  most  important  that  the  general  health 
of  the  mother  should  be  carefully  looked  after.  She  should  take  a  mod- 
erate amount  of  exercise  in  the  open  air,  have  sufficient  sleep  and  rest  and 
not  be  harassed  by  unnecessary  petty  household  details,  and  above  all  the 
quantity  and  quality  of  her  food  should  be  carefully  supervised  to  avoid 
gastrointestinal  disturbance.  She  should  eat  a  moderate  quantity  of  fruits, 
vegetables,  farinaceous  and  nitrogenous  food,  being  always  careful  that 
the  food  selected  is  easily  within  her  digestive  capacity.  Overeating,  eating 
at  irregular  hours,  drinking  more  than  a  very  moderate  amount  of  alcoholic 
stimulants  and  taking  highly  seasoned  dishes,  salads  and  foods  difficult  of 
digestion  are  to  be  carefully  avoided.  Constipation,  when  it  exists,  should 
be  overcome  by  proper  medicines  and  diet. 

The  quantity  of  the  milk  may  be  increased  by  improving  the  general 
health  of  the  mother,  by  massage  of  the  breasts  and  by  certain  foods,  such 
as  milk,  gruels  and  the  liquid  malt  extracts.  The  fat  may  be  increased  by 
meats,  eggs,  milk  and  the  liquid  malt  extracts,  and  may  be  diminished  by 
diminishing  the  quantity  of  these  foods  and  substituting  fruits,  vegetables, 
bread  and  cereals.  The  proteins  may  be  increased  by  rest  and  by  giving  an 
increased  quantity  of  meat  and  eggs,  and  they  may  be  lowered  by  exercise  in 
the  open  air  and  by  a  diminished  quantity  of  meat  and  eggs. 

Menstruation,  especially  in  neurotic  mothers,  may  so  change  the  char- 
acter of  the  milk  as  to  produce  slight  gastrointestinal  indigestion,  but  these 
disturbances  are  rarely  of  enough  importance  to  justify  corrective  measures 
of  any  kind. 

Nervous  impressions  produced  by  great  excitement,  grief  and  fright 
may  produce  temporary  changes  in  the  breast  milk  sufficient  to  cause  colic 
and  indigestion  in  the  infant,  and  prolonged  nervous  strain  and  worry 
9 


112  BEEAST   FEEDIXCt 

may  be  a  very  serious  factor  in  diminishing  the  quantity  and  quality  of  the 
breast  milk. 

Arsenic,  salicylic  acid,  alcohol,  iodin,  belladonna,  opium,  salts,  iodids, 
bromids,  cascara  and  senna  when  taken,  may  be  eliminated  through  the  milk 
in  sufficient  quantities  to  produce  gastrointestinal  indigestion  or  toxemia  in 
the  nursing  infant. 

Bacteria  are  occasionally  eliminated  in  the  milk,  but  the  danger  from 
this  source  is  exceedingly  slight.  Tubercle  bacilli,  typhoid  bacilli  and 
streptococci  are,  however,  sometimes  found  in  the  breast  milk  of  mothers 
suffering  from  the  constitutional  diseases  which  these  microorganisms 
produce.  The  acute  infectious  diseases  when  prolonged  and  severe,  such  as 
typhoid  fever  and  scarlet  fever,  contraindicate  nursing,  not  only  because  of 
the  danger  of  infection  to  the  child,  but  because  of  the  depletion  of  the 
mother.  Other  less  severe  infections,  such  as  measles,  influenza  and  even 
diphtheria  unless  it  be  very  severe,  should  not  interrupt  nursing.  In  these 
conditions  if  proper  precautions  are  taken  the  infant,  as  a  rule,  escapes 
the  disease,  or,  if  not,  contracts  it  in  a  very  mild  form  from  being  partially 
protected  by  the  antibodies  which  are  eliminated  through  the  milk,  and  the 
dangers  thus  incurred  are  much  less  than  those  incurred  by  weaning  the 
young  infant. 

A  syphilitic  infant  should  not  be  permitted  to  nurse  a  nonsyphilitic  wet 
nurse  any  more  than  a  syphilitic  wet  nurse  should  be  allowed  to  nurse  a  non- 
syphilitic  infant;  in  both  instances  the  disease  may  be  transferred.  A  con- 
genitally  syphilitic  infant,  however,  may  nurse  its  mother  without  danger 
of  communicating  the  disease. 

Active  tuberculosis  in  the  mother  is  an  absolute  contraindication  to 
nursing.  Mothers,  however,  who  have  recovered  from  active  tuberculosis 
may  under  urgent  conditions  be  allowed  to  nurse  their  offspring.  The 
danger  here,  however,  is  rather  to  the  mother  than  to  the  child,  inasmuch 
as  the  drain  upon  her  may  so  weaken  her  powers  of  resistance  that  a  latent 
tuberculosis  may  develop  into  an  active  one. 

General  debility,  malnutrition  and  pronounced  anemia  on  the  part  of 
the  mother,  as  a  rule,  contraindicate  nursing  unless  the  condition  be  a 
temporary  one  that  can  be  readily  removed  by  good  hygiene  and  medication. 


CHAPTEE  XII 

BREAST    FEEDING 

NORMAL  BREAST  FEEDING 

It  is  a  well-recognized  fact  that  in  healthy  mothers  the  regular  and 
vigorous  nursing  of  the  breasts  by  an  infant  strong  enough  to  nurse  is 
the  most  important  single  factor  in  stimulating  the  secreting  glands  of 
the  breast  to  perform  their  normal  physiological  function ;  that  is,  to  supply 


NORMAL   BREAST  FEEDING  113 

an  abundant  quantity  of  normal  milk.  As  Budin  says,  "the  quantity  of  the 
milk  varies  with  the  demand."  In  the  strong  and  vigorous  under  the 
stimulus  of  regular  nursings  the  breast  can  in  many  instances  be  made 
to  secrete  sufficient  milk  to  nourish  two  infants.  The  physician  should 
therefore  direct  that  the  infant  be  put  to  the  breast  within  four  or  five 
hours  after  birth,  and  during  the  first  three  days  it  is  induced  to  nurse 
as  vigorously  as  possible  at  intervals  of  four  to  six  hours,  dependent  upon 
the  condition  of  the  mother.  For  three  days  even  after  a  normal  labor 
the  mother  is  the  prime  consideration.  It  is  most  important  that  she  should 
have  proper  rest  and  sleep  undisturbed  by  regular  nursings  or  by  the  care 
of  her  baby.  The  nursings  during  this  time  promote  uterine  contractions, 
clear  the  breasts  of  colostrum  and  hasten  the  establishment  of  the  normal 
milk  secretion  on  the  third  or  fourth  day  of  nursing.  During  these  first 
days  it  is  important  that  the  infant  should  be  given  water  to  drink,  either 
in  the  form  of  pure  water,  a  milk-sugar  solution,  toast  water,  or  a  very  weak 
solution  of  cow's  milk,  one  of  water  to  five  of  milk.  A  few  teaspoonfuls  of 
one  of  these  mixtures  given  at  intervals  during  the  day  will  prevent  loss 
of  weight  and  furnish  water  for  washing  out  the  gastrointestinal  canal,  the 
kidneys,  and  other  excretory  organs.  If  the  milk  secretion  is  not  estab- 
lished by  the  third  day  the  milk  mixture  may  be  given  in  larger  quantities 
until  the  delayed  milk  secretion  is  established.  After  the  third  or  fourth 
day,  with  the  mother  thoroughly  convalescent,  regular  nursings  should 
be  commenced.  The  baby  should  then  be  nursed  every  two  hours  from  seven 
A.  M.  to  nine  P.  M.,  and  during  the  night  should  never  be  awakened  for  a 
feeding  or  put  to  the  breast  oftener  than  every  four  hours.  In  putting  the 
infant  to  the  breast  the  nipple  should  be  worked  out  so  that  the  child  can 
get  a  firm  grasp  on  the  entire  nipple.  It  should  be  allowed  to  nurse  in 
the  average  fifteen  minutes.  Where  the  milk  supply,  however,  is  insufficient 
the  time  may  be  prolonged  to  twenty  minutes,  but  during  this  time  the 
child  should  not  be  allowed  to  lie  with  the  nipple  in  its  mouth,  but  should 
be  kept  nursing.  When  the  baby  is  removed  from  the  breast  the  nipple 
should  be  cleansed  with  water  or  boracic  acid  solution,  and  if  there  be  any 
tenderness  about  the  nipple  it  should  be  washed  in  a  50  per  cent,  alcohol 
solution  and  dusted  with  dermatol  to  harden  and  heal  it.  If  there  be  ero- 
sions or  fissures  about  the  nipple  these  should  be  treated  after  each  nursing 
with  a  1  or  2  per  cent,  solution  of  nitrate  of  silver  and  the  baby  for  a  time  be 
made  to  nurse  through  a  nipple  shield.  Any  disease  of  the  nipple  should 
receive  prompt  and  careful  treatment,  as  it  may  lead  to  caking  of  the 
breast,  mastitis,  or  even  abscess.  The  latter  would  be  not  only  painful 
and  interfere  with  the  general  health  of  the  mother,  but  would  cause  the 
permanent  loss  of  that  breast  to  the  infant.  When,  therefore,  one  of  the 
breasts  becomes  swollen,  hard  and  tender,  accompanied  possibly  by  fever,  the 
baby  should  not  be  allowed  to  nurse  from  that  breast  until  the  inflammatory 
conditions  have  subsided,  and  the  mother  should  be  confined  to  bed  for  a 
few  days  with  hot  compresses  of  20  per  cent,  alcohol,  boracic  acid,  or  some 
other  antiseptic  held  over  the  breast  in  such  a  manner  as  to  lift  and  support 


114 


BREAST   FEEDING 


it.  During  this  time  a  breast  pump  may  be  used  from  time  to  time  to 
relieve  the  engorgement,  and  under  this  treatment  convalescence,  as  a  rule, 
quickly  results,  the  breast  is  restored  to  its  normal  condition,  and  the  baby 
may  again  be  allowed  to  nurse  both  breasts.  In  the  event  that  such  an 
emergency  temporarily  diminishes  the  milk  supply  of  the  infant  so  that  it 
is  insufficiently  nourished  it  may  be  given,  following  every  other  nursing,  a 
sufficient  quantity  of  modified  milk  to  make  up  the  deficiency. 


26 
25 
24 
23 
22 
21 
20 
19 
18 

Sl6 

Ol4 
0-13 
12 
II 
10 
9 
8 
7 
6 
S 


12342678910  12  14  16  IS  20  22  24  26  28  30  32  34  36  38  40  42  44  46  48  50  52 
AGE  IN  WEEKS 

Fig.  19. — Weight  Chart  of  Bheast-fed  Infant. 

The  intervals  between  the  feedings  are  increased  to  two  and  a  half 
hours  when  the  infant  is  two  months  old,  to  three  hours  when  it  is  four 
months  old,  and  to  four  hours  when  it  is  nine  months  old,  and  during  all 
of  this  time  the  baby  must  be  fed  at  regular  intervals,  awakened  on  the 
stroke  of  the  clock  during  the  day  and  made  to  go  as  long  as  possible  with- 
out nursing  between  ten  in  the  evening  and  six  in  the  morning.  From  the 
third  to  the  fifth  month  one  nursing  at  night  should  be  sufficient,  and  as 
soon  after  the  fifth  month  as  possible  the  baby  should  be  trained  to  go 
without  nursing  from  ten  at  night  until  six  in  the  morning.  It  is  re- 
markable how  a  normal  baby  fed  on  normal  milk  will  adapt  itself  to  the 
regular  hours  of  nursing,  and  in  such  infants  the  question  of  sleeping 
through  the  night  is  absolutely  a  matter  of  training.  In  a  baby  eight  or 
nine  months  of  age,  trained  to  sleep  the  night  through,^  the  habit  becomes 
so  firmly  fixed  that  it  is  rarely  disturbed  even  by  illness. 

MIXED  FEEDING 

When  it  has  been  determined  that  the  breast  milk  is  insufficient,  mixed 
feedings  should  be  resorted  to ;  that  is  to  say,  the  infant  is  to  be  given  the 
breast  at  regular  intervals,  followed  at  every  feeding  by  a  sufficient  quantity 
of  modified  milk  to  make  up  the  deficiency.    The  success  of  this  method  of 


MIXED  FEEDING  115 

feeding  depends  upon  tlie  following  facts:  First,  frequent  nursings  will 
stimulate  the  secretion  of  milk  and  give  the  baby  all  the  breast  milk  it  can 
possibly  obtain.  Second,  supplementing  every  nursing  with  the  bottle, 
instead  of  nursing  at  one  time  and  giving  the  bottle  at  another,  insures  suffi- 
cient nourishment  at  regular  intervals,  as  the  infant  has  the  option  of 
emptying  the  bottle  or  not  after  every  nursing;  while  by  the  alternate 
nursing  method,  breast  at  one  time  and  bottle  at  another,  it  may  be  a 
question  with  the  infant  of  a  feast  and  a  famine.  If  the  breast  milk  is 
insufficient  it  would  be  starved  at  alternate  feedings.  Third,  and  perhaps 
more  important  than  all,  is  the  fact  that  cow's  milk  is  more  easily  digested 
when  it  is  mixed  in  the  stomach  of  the  infant  with  breast  milk.  This  is 
perhaps  due  to  the  more  active  ferments  in  human  milk,  which  assist  in  the 
digestion  of  the  starches,  fat  and  proteins  of  cow's  milk.  At  any  rate,  it  is 
a  fact  which  clinical  experience  has  amply  demonstrated  that  cow's  milk 
is  more  easily  cared  for  by  the  infantile  digestive  organs  when  it  is  mixed 
with  human  milk.  The  importance  of  mixed  feeding  has  never  been  fully 
appreciated  by  the  medical  profession,  and  of  all  countries  America  is  the 
one  in  which  mixed  feeding  should  be  insisted  upon,  because  here  more  than 
in  European  countries  are  we  called  upon  to  supplement  mother's  milk  by 
artificial  food.  Mixed  feeding,  therefore,  in  the  sense  here  outlined,  is  one 
of  the  most  valuable  expedients  we  have  for  getting  good  nutritional  results 
in  the  feeding  of  infants. 

Before  dismissing  the  subject  of  mixed  feeding  I  wish  also  to  speak 
of  the  value  of  this  method  among  the  poor,  where,  because  of  their  loca- 
tion and  surroundings,  they  have  to  depend  upon  artificial  infant  foods 
to  supplement  nursing  during  the  summer  months.  During  these  hot 
months  these  artificial  foods,  such  as  condensed  milk,  malted  milk  and 
Nestle's  food,  are  life-savers  to  this  class  of  our  population.  It  is  absolutely 
impossible  for  city  authorities  to  arrange  that  the  poor  of  the  city  shall 
have  the  proper  medical  attention,  and  be  furnished  with  a  clean  and  prop- 
erly modified  milk,  with  the  facilities  for  caring  for  the  same.  All  of  these 
things  are  absolutely  necessary  to  insure  the  success  of  artificial  feeding 
with  modified  milk.  It  becomes  necessary  therefore  for  the  poor  of  our 
cities,  in  the  vast  majority  of  instances  where  the  breast  milk  is  insufficient, 
to  resort  to  cheap,  easily  prepared  and  easily  cared  for  artificial  foods  to 
supplement  the  breast  feedings.  In  such  instances  and  under  such  condi- 
tions it  is  to  be  strongly  recommended  that  these  artificial  foods  should 
follow  the  breast  feedings.  The  breast  milk  in  this  form  of  artificial  feed- 
ing will  in  large  part  prevent  the  scurvy,  rickets,  and  other  malnutritions 
that  commonly  follow  the  long-continued  exclusive  use  of  these  proprietary 
foods.  This  method  of  mixed  feeding  with  proprietary  foods  has  been  suc- 
cessful in  my  hands;  I  have  utilized  it  in  my  dispensary  work,  and  oft- 
times  in  my  private  practice,  where  the  conditions  were  such  that  modified 
milk  could  not  be  safely  used. 


116  BREAST   FEEDING 

WEANING 

The  question  of  weanin,g  an  infant  is  altogether  an  individual  one,  de- 
pending upon  the  individual  conditions  which  one  has  to  face  in  each  in- 
stance. On  general  principles,  however,  it  may  be  stated  that  the  infant 
from  birth  should  be  accustomed  to  taking  a  little  water  in  addition  to 
breast  milk,  not  that  tliis  water  is  necessary  after  the  milk  secretion  is 
established,  but  that  it  is  a  good  thing  to  accustom  the  baby  to  taking  some 
other  fluid  than  breast  milk  and  to  take  it  in  a  different  way,  either  from 
the  spoon  or  from  a  bottle.  This,  as  a  rule,  obviates  the  difficulty  which  is 
occasionally  encountered  of  starving  the  baby  into  taking  artificial  food. 
It  is  also  a  good  practice  even  in  perfectly  nourished  breast-fed  babies, 
after  the  third  or  fourth  month,  to  give  them  one  bottle  of  modified  milk 
as  a  substitute  for  one  nursing  in  the  twenty-four  hours.  This  serves  the 
double  purpose  of  educating  the  infantile  digestive  organs  to  the  digestion 
of  cow's  milk  and  of  giving  the  nursing  mother  the  opportunity  of  getting 
away  from  home  and  its  duties  for  a  brief  period  during  the  day.  This 
relieves  the  mother  of  a  certain  amount  of  nervous  strain  and  promotes 
her  health  and  strength. 

As  time  goes  on  in  a  perfectly  normal  breast-fed  baby  the  number  of 
modified  milk  feedings  is  to  be  increased,  so  that  at  eight  or  nine  months 
the  child  is  to  have  at  least  two  feedings  of  modified  milk  in  twenty-four 
hours.  Within  the  next  three  months  the  number  of  feedings  of  modified 
milk  is  gradually  increased  until  the  infant  at  one  year  of  age  is  weaned. 
The  time  of  weaning,  however,  even  in  a  normal  child,  may  vary  with  the 
season  of  the  year  and  with  the  health  of  the  mother.  If  the  birthday  of 
the  child  comes  during  the  hot  months  of  summer  it  may  perhaps  be  well 
to  continue  to  give  the  child  a  few  feedings  of  breast  milk  each  day  until 
it  is  thirteen  or  fourteen  months  of  age,  as  this  would  enable  the  physician 
to  utilize  the  breast  milk  in  the  emergency  of  any  acute  illness  on  the  part 
of  the  gastrointestinal  canal.  In  any  event,  whatever  the  conditions  may 
be,  it  is  much  better,  if  possible,  to  wean  the  child  gradually,  letting  it  have 
the  advantage  of  all  the  breast  milk  it  can  get  for  the  first  seven  or  eight 
months,  and  then  during  the  next  four  months  slowly  educate  its  diges- 
tive organs  to  the  digestion  of  cow's  milk.  Sudden  weaning  is  justified  only 
where  acute  conditions  of  ill  health  on  the  part  of  the  mother  make  it  abso- 
lutely necessary.  Weaning  during  the  hot  months  of  summer  is  to  be 
avoided  if  possible,  and  this  is  perhaps  always  possible  under  the  method  of 
mixed  feeding  outlined  above.  It  is,  of  course,  not  always  possible  to  solely 
consider  the  interests  of  the  infant  as  to  the  time  of  weaning.  The  mother's 
health  may  demand  that  the  child  be  weaned  as  early  as  the  second,  third 
or  fourth  months,  but  in  such  instances  the  method  of  mixed  feeding  given 
above  should  be  used. 


THE   WET   NURSE  117 


THE  WET  NURSE 


The  conditions  in  America  are  such  that  the  wet  nurse  is  not  as  com- 
monly used  for  breast-feeding  the  infant  as  in  Europe.  This  is  because 
the  class  of  women  who  are  willing  to  undertake  this  service  are  morally 
and  physically  of  a  much  lower  type,  and  yet  it  is  possible  to  secure  a  more 
or  less  satisfactory  wet  nurse  when  the  emergency  arises  which  demands 
one.  The  wet  nurse  may  be  necessary  to  start  the  infant  when  the  mother's 
milk  cannot  be  used.  This  is  especially  true  in  premature  infants  or  in 
malnourished  infants  born  of  tuberculous  or  otherwise  diseased  parents. 
It  is  also  sometimes  absolutely  necessary  following  acute  gastrointestinal 
diseases  in  the  bottle-fed  infant  when  other  foods  cannot  be  found  upon 
which  the  infant  can  thrive.  The  physician  must  always  bear  in  mind  that 
a  premature  or  malnourished  infant  that  is  doing  badly  under  artificial 
feeding  will  probably  continue  to  grow  worse  in  spite  of  changes  in  arti- 
ficial foods,  and  that  such  an  infant  may  be  expected  to  improve  under  good 
wet  nursing.  Wet  nursing  is  to  be  preferred  to  artificial  feeding  in  every 
such  instance.  Our  knowledge  of  artificial  feeding,  however,  has  been  so 
much  improved  of  late  that  in  the  great  majority  of  instances  an  infant 
can  be  successfully  fed,  supplying  all  its  nutritional  demands.  This  fact, 
together  with  the  fact  that  satisfactory  wet  nurses  are  difficult  to  find  and 
that  they  are  undesirable  members  of  a  household,  decides  the  mother  in 
most  instances  to  undertake  the  slight  additional  risk  of  artificially  feeding 
her  infant  rather  than  undergo  the  expense  and  suffer  the  annoyance  which 
the  installation  of  a  wet  nurse  would  entail.  It  is  therefore  the  important 
duty  of  the  physician  to  determine  in  individual  cases  when  a  wet  nurse  is 
necessary. 

Selection  of  a  Wet  Nurse. — A  wet  nurse  must  be  free  from  all  signs  of 
tuberculosis,  syphilis,  and  other  chronic  diseases.  She  should  be  in  good 
physical  condition,  presenting  the  appearance  of  a  woman  capable  of  sup- 
plying sufficient  milk  to  an  infant  without  injury  to  her  own  health.  She 
should  also  be  comparatively  young,  preferably  a  primipara,  and  her  baby 
should  be  over  one  month  and  less  than  seven  months  of  age.  Her  own 
infant  is  the  best  indication  of  her  fitness  for  wet  nursing;  it  should  show 
by  its  physical  development  that  it  has  obtained  a  sufficient  quantity  of 
breast  milk  to.  supply  its  nutritional  demands.  There  must  also  be  a  dis- 
tinct understanding  with  the  wet  nurse  before  she  is  employed  that  she 
will  conform  to  the  rules  of  diet  and  hygiene  necessary  to  produce  the  best 
results  in  furnishing  a  milk  suitable  to  the  nutritional  demands  of  the  infant 
she  is  to  serve. 


118  ARTIFICIAL  FEEDING  OF  INFANTS 

CHAPTER  XIII 
FOOD   MATERIALS    USED   IN   THE  ARTIFICIAL   FEEDING   OF   INFANTS 

COW'S  MILK 

Fresh  Cow's  Milk. — Cow's  milk  is  the  food  almost  universally  recom- 
mended for  the  artificial  feeding  of  infants. 

The  most  important  property  of  good  cow's  milk  is  cleanliness.  There 
is  little  or  no  difficulty  in  obtaining  clean  milk  in  the  country  and  in  small 
towns,  provided  the  ordinary  rules  of  stable  hygiene  and  personal  cleanli- 
ness in  the  handling  of  the  milk  are  observed.  In  large  cities  the  problem 
is  a  very  different  one,  since  the  milk  has  to  be  transported  long  distances, 
pass  through  many  hands  and  the  time  between  the  milking  and  the  con- 
sumption of  the  milk  is  greatly  increased. 

The  great  superiority  of  clean  raw  milk  as  an  infant  food  over  all  other 
artificial  foods  has  been  so  universally  recognized  in  recent  years  that  all 
of  our  large  cities  have  made  most  strenuous  efforts  to  obtain  clean  raw 
milk.  The  pioneer  methods  employed  by  the  Walker-Gordon  laboratories 
under  the  advice  of  Rotch,  and  the  successful  movement  of  Coit  by  which  he 
was  able  to  put  upon  the  market  a  clean  milk  under  the  name  of  "certified 
milk,"  are  largely  responsible  for  the  methods  now  employed  in  furnishing 
clean  milk  to  our  large  cities.  These  movements  have  resulted  in  the  es- 
tablishment of  model  dairy  farms  so  located  that  the  rapid  transportation 
of  milk  from  the  country  to  the  city  is  possible.  In  the  management  of 
these  farms  the  following  conditions  are  necessary: — The  cows  must  be 
healthy  and  free  especially  from  tuberculosis;  the  stables  must  be  clean 
and  well  ventilated  and  the  barnyards  free  from  manure  and  kept  in  as 
sanitary  a  condition  as  possible;  the  water  supply  used  for  dairy  purposes 
should  be  pure ;  the  food  of  the  cows  should  be  free  from  ensilage,'  strongly 
flavored  weeds  and  distillery  and  brewery  slops.  The  cows  should  be  kept 
clean  by  daily  grooming  and  the  milking  should  be  done  with  clean  hands 
from  clean  udders  into  clean  pails,  using  every  precaution  to  prevent  the 
early  contamination  of  the  milk.  The  first  few  strains  of  milk  from  each 
udder  should  be  discarded.  The  milk  should  be  immediately  removed  to 
a  separate  building,  where  it  is  rapidly  cooled,  bottled,  and  then  placed  in 
a  refrigerator  until  it  starts  on  its  journey  to  the  city.  In  the  carrying 
of  the  milk  to  its  destination  it  should  be  kept  cool  and  should  reach  the 
consumer  with  a  bacterial  content  not  above  10,000  to  the  c.  c.  Milk  fur- 
nished under  these  conditions  may  be  fed  in  a  raw  state  with  safety  to  the 
infant. 

The  health  boards  and  medical  societies  of  our  cities,  following  the 
initiative  of  Coit,  have  selected  a  board  of  chemists  and  bacteriologists 
whose  duty  it  is  to  make  frequent  examinations  of  this  milk  as  it  is  de- 
livered to  the  consumer.     These  examinations  determine  the  bacterial  con- 


COW'S   MILK  119 

tent  of  the  milk,  the  amount  of  butter  fat  it  contains,  the  relative  per- 
centage of  its  various  ingredients,  and  the  presence  or  absence  of  chemical 
preservatives  and  other  foreign  matter.  When  the  milk  of  the  individual 
dealer  always  conforms  to  the  standards  set  by  the  medical  boards  he  is 
furnished  with  labels  containing  the  words  "certified  milk."  These  labels 
when  placed  upon  the  bottles  are  a  guarantee  to  the  consumer  that  the  con- 
tained milk  conforms  in  all  respects  to  the  standards  laid  down  by  the 
medical  authorities. 

The  "certified  milk"  which  is  sold  in  nearly  all  of  our  large  cities  con- 
forms to  the  following  standards :  First,  freedom  from  pathogenic  bacteria ; 
second,  a  bacterial  content  not  exceeding  10,000  to  the  c.  c. ;  third,  freedom 
from  dirt  and  other  foreign  organic  matter ;  fourth,  freedom  from  chemical 
preservatives ;  fifth,  a  constant  nutritive  value  with  about  4  per  cent,  of  fat 
and  a  proper  percentage  of  proteins  and  carbohydrates. 

It  is  plainly  evident  that  milk  of  this  character  constantly  supervised 
by  competent  chemists  and  bacteriologists  is  a  great  boon  to  every  large 
city,  but  it  is  also  evident  that  the  production  of  this  class  of  milk  requires 
an  unusual  outlay  of  money  on  the  part  of  the  dairymen  and  must  there- 
fore be  sold  at  a  price  that  is  absolutely  prohibitive  to  the  poor  of  our  cities. 
For  this  reason  in  most  of  our  large  cities  a  second  grade  of  milk  is  fur- 
nished by  the  same  dairies  and  under  the  supervision  of  the  same  board 
of  milk  inspectors.  The  commercial  name  of  this  milk  is  "inspected  milk" 
and  it  bears  such  a  label  testifying  to  its  relative  cleanliness.  "Inspected 
milk"  differs  from  "certified  milk"  chiefly  in  the  standards  required  for  its 
bacterial  content.  During  the  winter  months  it  must  not  contain  more 
than  60,000  bacteria  to  the  c.  c,  and  during  the  summer  months  not  more 
than  100.000  to  the  c.  c.  In  other  bacteriological  and  chemical  standards 
it  is  on  the  same  plane  as  "certified  milk,"  and  sells  a  few  cents  cheaper 
by  the  quart. 

Sterilized  Milk. — But  notwithstanding  the  efforts  of  health  boards  and 
medical  societies  it  is  impossible  to  put  upon  the  market  in  large  cities  a 
clean  milk  at  a  price  within  the  reach  of  the  poor.  The  "certified  and  in- 
spected milks"  can  be  utilized  only  in  the  feeding  of  a  comparatively  small 
percentage  of  the  infant  population  of  our  large  cities.  For  this  reason 
sterilization  and  pasteurization  of  milk  still  remain  most  important  life- 
saving  measures  in  the  feeding  of  infants  during  the  summer  months,  when, 
because  of  the  heat,  milk  contamination  increases  rapidly.  It  must  be  re- 
membered, however,  that  unclean  milk — that  is,  milk  that  contains  a  large 
number  of  microorganisms — ^has  undergone  fermentative  changes  which 
injure  its  nutritive  value  and  which  may  have  produced  poisonous,  irritating 
bodies  which  make  it  a  dangerous  food  for  infants.  Milk  thus  contaminated 
cannot  be  made  wholesome  by  sterilization,  so  that  when  pasteurization  or 
sterilization  are  resorted  to  as  a  means  of  preventing  further  bacterial  con- 
tamination it  is  necessary  to  start  with  as  clean  a  milk  as  possible. 

Cow's  milk  may  be  sterilized  by  heating  to  212°  F.,  or  100°  C,  for 
twenty  minutes.     This  produces  what  is  ordinarily  termed  sterilized  milk. 


120  ARTIFICIAL  FEEDING  OF  INFANTS 

The  heat  destroys  all  the  developed  bacteria,  but  does  not  destroy  the  spores, 
and  the  milk  is  therefore  not  absolutely  sterile,  since  these  spores,  after  a 
time,  may  develop  bacteria.  The  sporulated  bacteria,  however,  are  not  of 
enough  importance  to  justify  the  further  application  of  heat.  Sterilization 
of  milk  may  be  accomplished  by  means  of  the  Arnold  Steam  Sterilizer,  or  by 
placing  the  milk  bottles  in  boiling  water  for  twenty  minutes.  The  latter 
process  is  of  great  practical  value  among  the  poor  of  our  large  cities  be- 
cause of  its  simplicity  and  cheapness. 

The  advantages  derived  from  sterilizing  milk  are  as  follows :  It  results 
in  a  loss  of  acidity  on  the  part  of  the  milk,  which  causes  a  retardation  in 
rennin  coagulation  and  thereby  causes  the  casein  to  be  precipitated  in  finer 
flakes  so  that  it  is  more  readily  acted  upon  by  digestive  ferments;  large 
casein  curds  never  form  in  this  milk.  The  fermentative  processes  are 
stopped  and  the  milk  is  not  further  contaminated  by  bacteria.  This  is  the 
prime  object  in  the  sterilization  of  milk,  and  greatly  reduces  the  dangers 
of  milk  poisoning.  Sterilization  is  the  cheapest  way  of  preserving  milk. 
In  fact,  it  is  the  only  practical  way  by  which  it  may  be  kept  wholesome 
for  use  among  the  children  of  the  poor  in  our  large  cities.  These  people 
cannot  afford  and  cannot  care  for  clean,  raw  milk.  So  with  them  the  only 
available  safe  substitute  in  hot  weather  for  condensed  milk  and  the  patent 
milk  foods  is  sterilized  milk.  With  infants  capable  of  digesting  sterilized 
milk  it  serves  nutritional  purposes  much  better  than  proprietary  foods. 

The  disadvantages  which  are  said  to  result  from  sterilizing  milk  are 
as  follows :  Decomposition  of  nuclein ;  separation  of  phosphorus  from  its 
organic  union;  partial  coagulation  of  soluble  proteins;  partial  destruction 
of  the  fat  emulsion ;  increased  difficulty  in  the  digestion  of  casein ;  partial 
precipitation  of  citric  acid  as  an  insoluble  calcium  citrate;  partial  conver- 
sion of  milk  sugar  into  caramel;  partial  separation  of  the  lime  salts  from 
their  combination  with  calcium,  thereby  rendering  theia  less  easily  ab- 
sorbed; partial  loss  of  carbonic  acid,  oxygen  and  nitrogen,  which  are  ex- 
pelled by  heating;  complete  destruction  of  ferments,  alexins,  agglutinins 
and  other  live  principles  in  the  milk.  These  changes  represent  a  distinct 
nutritional  loss  to  the  infant  in  that  the  important  ingredients  of  the  milk 
are  rendered  somewhat  less  digestible  and  assimilable.  Sterilized  milk  also 
has  a  tendency  to  produce  constipation  with  its  resultant  intestinal  intoxi- 
cations. 

Pasteurized  Milk.— When  the  medical  profession  awoke  to  the  disad- 
vantages of  sterilized  milk  it  began  to  experiment  with  lower  temperatures, 
hoping  in  that  way  to  destroy  the  developed  bacteria  without  producing  im- 
portant chemical  and  biological  changes  in  the  milk.  Koplik  suggested  the 
heating  of  milk  for  infant  feeding  at  a  lower  temperature  and  Monti  rec- 
ommended a  temperature  of  180°  F.,  and  this  process,  in  contradistinction 
to  sterilization,  was  called  pasteurization.  Freeman  has  done  very  valuable 
work  in  popularizing  a  still  lower  temperature  of  pasteurizing  which  kills 
the  greater  portion  of  the  developed  bacteria  and  yet  produces  no  serious 
chemical  or  biological  changes  in  the  milk.    This  process  is  very  generally 


COW'S   MILK 


121 


used  in  this  country,  especially  in  our  large  cities  during  the  summer 
months,  and  when  properly  used  is  a  most  important  life-saving  measure. 

The  Freeman  Pasteurizer  may  be  used  for  this  purpose,  and  Freeman's 
conclusions  are  as  follows :  First,  milk  for  infant  feeding  should  be  pasteur- 
ized so  as  not  to  interfere  with  its  biological  properties  or  chemical  com- 
position, but  at  a  sufficient  temperature  to  destroy  the  bulk  of  the  bacteria 
present,  including  the  tubercle  bacilli.  Second,  a  temperature  of  140°  F. 
(60°  C.)  continued  for  forty  minutes  would  seem  to  fulfil  these  indica- 
tions. Freeman  also  says  the  question  "concerning  the  effect  of  heat  on 
ferments  has  been  carefully  worked  out  by  Hippius.  The  salol-splitting  fer- 
ment found  only  in  mother's  milk  was  weakened  by  a  temperature  of  131° 
F.  (55°  C.)  and  destroyed  by  149°  F.   (65°  C),  while  the  amylolytic  fer- 


FiG.  20. — Freeman's  Pasteurizer. 
A,  Bottles  in  position  for  heating;  B,  method  of  cooling. 

ment  found  only  in  mother's  milk  was  weakened  by  a  temperature  of  158° 
F.  (70°  C.)  and  destroyed  by  167°  F.  (75°  C.)." 

It  seems  evident  therefore  that  the  pasteurization  of  milk  when  care- 
fully done  may  serve  the  purpose  of  checking  the  fermentative  processes 
without  materially  changing  its  chemical  composition  or  biological  proper- 
ties, and  clinical  experience  strengthens  this  opinion  since  milk  pasteurized 
at  low  temperatures  may  be  fed  for  a  long  time  with  practically  the  same 
results  as  are  obtained  from  fresh,  clean  raw  milk.  Pasteurized  milk,  how- 
ever, requires  time,  care  and  intelligence  in  its  preparation,  and  also  re- 
quires a  subsequent  refrigerator  temperature  to  prevent  bacterial  contamina- 
tion. It  is  therefore  not  commonly  available  for  use  among  the  poor  of  our 
large  cities.  It  has,  however,  a  large  field  of  usefulness  among  those  city 
dwellers  who  have  the  time  and  intelligence  to  prepare  it  and  the  facilities 
to  care  for  it  after  its  preparation,  since  in  our  large  cities  even  the  best 
available  milk  during  the  hot  summer  months  is  rendered  safer  by  pasteuri- 
zation. 

Peptonized  Milk.  — Milk  may  be  partially  or  wholly  peptonized  for  the 
purpose  of  feeding  premature  infants,  malnourished  infants  and  those  suf- 
fering from  acute  or  chronic  gastrointestinal  disorders.  In  the  handling 
of  this  class  of  infants  there  is  unquestionably  a  field  for  the  use  of  pep- 


122  ARTIFICIAL  FEEDING  OF  INFANTS 

tonized  milk.  Many  infants  with  feeble  digestive  capacity  are  capable  of 
digesting  and  assimilating  modified,  peptonized  milk  in  sufficient  quanti- 
ties to  prevent  rickets  and  other  malnutritions  which  would  follow  if  they 
were  fed  upon  very  weak  milk  mixtures.  There  are  many  children  also  who, 
after  a  long  and  severe  gastrointestinal  illness,  do  not  recover  for  many 
months  their  capacity  to  digest  unchanged  milk.  These  children  com- 
monly thrive  on  peptonized  milk,  and  it  is  sometimes  even  necessary  to 
keep  them  on  it  until  they  reach  the  age  when  other  foods  may  be  added 
to  their  diet.  In  recommending  peptonized  milk  it  is  also  important  to 
call  attention  to  the  fact  that  the  child's  digestive  capacity  may  remain 
undeveloped  if  the  peptonized  milk  be  too  long  continued.  As  Chapin  has 
forcibly  noted  the  stomach  of  the  infant  must  be  gradually  educated  to 
digest  milk,  and  this  physiological  process  influences  the  anatomical  and 
physiological  development  of  the  digestive  organs.  The  physician  must 
therefore  not  abuse  the  use  of  peptonized  milk,  nor  on  the  other  hand 
should  he  condemn  the  infant  to  rickets  or  other  forms  of  malnutrition 
because  of  his  fear  that  peptonized  milk  may  weaken  the  infant's  digestive 
capacity.  Partially  peptonized  milk  is  prepared  by  using  peptonizing 
tubes,  one  tube  to  a  pint  of  milk,  with  a  little  bicarbonate  of  soda  to  pre- 
vent coagulation.  The  milk  is  peptonized  at  a  temperature  of  110°  F.  for 
ten  or  fifteen  minutes  and  then  immediately  placed  on  ice  to  stop  further 
peptonization.  If  after  standing  for  several  hours  the  peptonized  milk  is 
so  bitter  that  the  infant  will  not  take  it,  sufficient  cane  sugar  may  be  added 
for  sweetening  purposes.  It  is  better  not  to  boil  the  milk  after  peptoniza- 
tion, as  this  destroys  the  peptonizing  ferments  that  have  been  added  to  the 
milk  and  produces  other  undesirable  changes  in  the  milk  which  have  been 
previously  referred  to.  It  may  be  necessary  in  some  instances  to  com- 
pletely peptonize  the  milk.  This  is  done  in  the  same  manner  as  above 
described  except  that  the  milk  is  kept  warm  and  the  peptonizing  process 
continued  for  one  and  a  half  to  two  hours.  This  process  makes  the  milk 
bitter  and  it  is  always  necessary  to  overcome  this  bitter  taste  with  cane 
sugar  or  saccharin. 

Buttermilk. — Buttermilk  as  a  food  for  infants  deserves  careful  con- 
sideration. It  has  long  been  successfully  used  in  Holland.  In  recent  years 
the  experience  of  physicians  the  world  over  has  demonstrated  that  it  may 
be  a  valuable  substitute  for  cow's  milk  in  infants  suffering  from  various 
forms  of  gastrointestinal  disturbance.  Buttermilk  used  in  infant  feeding 
is  commonly  made  from  cream  or  milk  that  has  soured  naturally.  The 
souring  process  in  the  milk,  however,  may  be  started  or  hastened  by  inoccu- 
lation  with  sour  milk  or  with  lactic  acid  bacilli  from  a  culture.  The  latter 
process,  however,  is  not  commonly  practicable  for  the  general  practitioner. 
The  composition  of  buttermilk  varies.  In  the  average,  however,  it  contains 
about  1  per  cent,  of  fat,  4  per  cent,  of  sugar,  and  3  per  cent,  of  proteins. 
It  has  a  food  value  of  about  400  calories  to  the  quart.  It  is  commonly  pre- 
pared for  infant  feeding  as  follows :  To  one  quart  of  buttermilk  are  added 
two  level  tablespoonfuls  of  wheat  flour  and  one  level  tablespoonful  of  cane 


COW'S   MILK  123 

sugar.  This  mixture  is,  with  constant  vigorous  stirring,  slowly  brought  to 
the  boiling  point  and  kept  there  for  twenty  minutes,  and  then  allowed  to 
cool.  The  constant  stirring  prevents  the  coagulation  of  casein.  Butter- 
milk prepared  in  this  way  has  the  same  percentage  of  fat  and  protein  as 
above  given,  but  the  carbohydrates  have  been  increased  to  10  per  cent,  and 
the  food  value  of  the  mixture  has  been  increased  to  600  calories  per  quart. 
This  buttermilk  mixture,  when  considered  from  the  standpoint  of  infant 
foods,  contains  a  low  percentage  of  fat  and  a  comparatively  high  percentage 
of  proteins  and  a  very  high  percentage  of  carbohydrates.  The  casein  is 
very  finely  divided,  separated  from  its  calcium  base  and  appears  in  the  form 
of  the  lactate  of  casein  which  cannot  be  acted  upon  by  rennet,  but  which  is 
readily  digested  by  the  intestinal  ferments.  The  acidity  varies  in  the 
neighborhood  of  0.5  per  cent.  The  chief  value  therefore  which  buttermilk 
has,  when  prepared  as  above  described,  lies  in  the  comparatively  large  quan- 
tity of  easily  digested  casein  which  it  contains,  the  small  amount  of  fat,  and 
the  large  quantity  of  easily  digested  carbohydrate  which  substitutes  for  the 
fat  in  serving  the  nutritional  demands  of  the  body.  Buttermilk,  notwith- 
standing the  fact  that  it  may  be  used  in  the  feeding  of  well  infants  for  some 
months  at  a  time  without  producing  apparent  nutritional  disturbances,  is 
an  ill-balanced  food  mixture,  not  capable  of  satisfying  the  full  nutritional 
demands  of  the  rapidly  growing  infant.  It  is  to  be  used  therefore  as  a 
food  for  normal  infants  only  when  properly  modified  cow's  milk  cannot  be 
obtained.  Its  real  field  of  usefulness,  however,  is  as  a  substitute  for  cow's 
milk  in  infants  who  are  suffering  from  gastrointestinal  disturbances  and 
who  are  not  capable  of  digesting  cow's  milk.  It  has  been  used  with  success 
in  chronic  and  subacute  gastroenteritis,  infantile  atrophy  and  acute  gastro- 
intestinal indigestion.  This  buttermilk  mixture  may  be  modified  by  the 
addition  of  boiled  water  to  suit  the  age  and  digestive  capacity  of  the  infant. 
rinkelstein's  Albumin  Milk, — Take  one  quart  of  boiled  milk;  after  it 
is  cool  remove  from  the  top  the  thick  scum,  then  add  to  it  a  liquid  rennet 
(1  ounce  of  commercial  essence  of  pepsin)  and  allow  it  to  coagulate  for 
one  hour  at  a  temperature  of  42°  C.  in  a  warm  bath.  Then  thoroughly 
stir  so  as  to  break  the  coagulated  casein  into  fine  particles,  and  pour  it  into 
a  bag  of  cheesecloth  to  drip  for  one  hour.  The  casein  is  then  removed  from 
the  bag  and  stirred  into  a  pint  of  water  and  worked  with  a  wooden  spoon 
through  a  fine  sieve.  A  pint  of  boiled  buttermilk  is  then  added  and  the 
whole  mixture  is  again  worked  through  a  fine  sieve  until  the  casein  is  so 
finely  broken  up  that  it  looks  like  ordinary  milk.  I  have  had  a  large  and 
favorable  experience  during  the  last  two  years  with  Finkelstein's  milk  pre- 
pared as  above  directed.  This  mixture  is  said  to  contain  3  per  cent,  of 
protein,  2.5  per  cent,  of  fat,  1.5  per  cent,  of  sugar,  and  0.5  per  cent,  of  ash. 
It  is  therefore  almost  a  sugar-free  mixture  very  rich  in  casein  and  con- 
taining a  fair  percentage  of  fat.  It  is  recommended  in  sugar  intoxications. 
I  have  found  it  of  special  value  in  infants  under  two  years  of  age  suffering 
from  chronic  gastrointestinal  indigestion.  Under  this  food  very  commonly 
fever,  diarrhea  and  toxic  symptoms  subside  and  the  infant  gains  in  strength. 


124  ARTIFICIAL  FEEDING  OF  INFAI^TS 

stops  losing  weight  and  in  some  instances  there  is  a  slight  gain.  After 
this  mixture  has  been  used  for  two  or  three  weeks  I  have  found  it  advisable 
to  begin  the  use  of  codliver  oil ;  with  this  addition  the  infant  commences  to 
gain  In  weight,  and  thereafter  thick  cereal  gruels  in  small  quantities  may 
be  added.  Later,  as  the  infant  becomes  convalescent,  ordinary  modified 
milk  fornmlas  may  be  gradually  substituted  and  the  Finkelstein  milk  dis- 
continued. During  the  use  of  this  formula  constipation  must  be  combated 
by  the  use  of  milk  of  magnesia  or  some  other  laxative. 

Malt  Sonps.-Malt  soups,  introduced  by  Keller  (Breslau),  will  some- 
times agree  with  infants  that  have  failed  to  thrive  on  the  ordinary  milk 
formulas.  These  soups  are  rich  in  carbohydrates  and  weak  in  fat  and  pro- 
tein. The  excess  of  carbohydrate  is,  however,  well  borne,  and  Keller  be- 
lieves that  in  malt  soups  less  protein  is  lost  by  intestinal  fermentation  and 
therefore  more  absorbed  than  in  other  milk  foods.  However  this  may  be, 
the  fact  remains  that  the  "malt  soup"  is  of  value  in  the  feeding  of  some 
difficult  cases.  It  is  made  as  follows:  One  ounce  (by  weight)  of  wheat 
flour  is  rubbed  up  with  enough  cold  milk  to  prevent  lump  forming  and  then 
mixed  with  10  ounces  of  milk.  This  is  heated  slowly  with  constant  stirring 
for  twenty  minutes  and  allowed  to  cool.  In  a  separate  vessel  dissolve  3 
ounces  of  one  of  the  thick  malt  extracts  (such  as  Maltine  or  Maltzyme)  in 
20  ounces  of  lukewarm  water  which  contains  15  grains  of  potassium  car- 
bonate. This  is  then  added  to  the  milk  and  flour  mixture  and  kept  warm 
for  two  or  three  minutes  and  then  rapidly  heated  with  constant  stirring  for 
five  minutes.  Cool  and  the  mixture  is  ready  for  use.  It  may  be  diluted,  if 
necessary,  for  young  infants. 

Skimmed  Milk. — Skimmed  milk  has  only  about  1  or  II/2  per  cent,  of 
fat,  but  it  has  practically  the  same  amount  of  sugar  and  protein  as  whole 
milk.  It  is  of  great  value  as  a  substitute  for  whole  milk  in  infants  suffer- 
ing from  gastrointestinal  disturbances  and  in  all  other  cases  where  there 
is  an  inability  to  digest  the  fat  of  cow's  milk.  Experience  has  demonstrated 
that  skimmed  milk  has  a  wide  field  of  usefulness  as  a  temporary  food  in 
these  cases.  It  should  be  modified  by  the  addition  of  a  carbohydrate  mix- 
ture to  suit  the  age  of  the  infant,  and  if  it  is  given  for  any  length  of  time 
the  carbohydrates  should  be  added  in  excess  to  make  up  in  caloric  value  for 
the  loss  in  fat.  As  the  infant  regains  its  capacity  for  fat  digestion  the 
quantity  of  carbohydrates  should  be  gradually  diminished  and  the  fat  grad- 
ually increased  so  as  to  prevent  nutritional  disturbances  which  might  result 
from  the  long-continued  use  of  a  food  markedly  deficient  in  fat. 

CARBOHYDRATES 

Carbohydrates,  including  the  sugars  and  starches,  play  a  most  important 
role  in  modified  milk  mix-tures. 

Milk  Sugar.— Milk  sugar  has  for  many  years  been  in  high  favor  be- 
cause it  is  a  natural  ingredient  of  milk  and  because  it  can.  as  a  rule,  be  fed 
in  sufficient  quantities  to  produce  good  nutritional  results  without  pro- 


CARBOHYDRATES  126 

ducing  gastrointestinal  disturbances.  Milk  sugar,  however,  is  more  sus- 
ceptible to  fermentation  and  is  not  so  readily  assimilated  as  maltose  and 
dextrin,  and  is  therefore  not  an  infrequent  cause  of  intestinal  fermentation 
and  of  the  symptom  group  elsewhere  spoken  of  under  the  term  "sugar  in- 
toxication." On  the  whole,  however,  milk  sugar  is  a  safe  and  satisfactory 
form  in  which  to  administer  carbohydrates.  It  is  commonly  used  in  5  to 
7  per  cent,  solutions  dissolved  in  boiling  water.  But  when  fermentative 
changes  occur  in  the  intestinal  canal  the  milk  sugar  should  be  suspected 
as  the  primary  cause  and  the  quantity  of  sugar  diminished  or  a  maltose- 
dextrin  mixture  substituted  for  the  milk  sugar. 

Cane  Sugar. — Cane  sugar  may  also  be  used  in  the  same  manner  as  milk 
sugar,  but  because  of  its  sweetness  it  cannot,  as  a  rule,  be  used  in  large 
enough  quantities  to  supply  the  carbohydrate  demand  of  a  modified  milk 
mixture,  and  when  given  in  excess  commonly  causes  a  fermentative  diarrhea. 
Cane  sugar,  however,  is  very  commonly  used  in  small  quantities  to  sweeten 
cereal  decoctions.  Cane  sugar,  like  milk  sugar,  may  also  produce  intestinal 
fermentation,  and  when  this  occurs  it  should  be  discontinued  and  a  mal- 
tose-dextrin mixture  substituted. 

Maltose. — ^laltose  has  for  many  years  been  considered  one  of  the  most 
valuable  of  infant  foods  in  modifying  milk  formulas;  but  the  German 
school  in  the  last  few  years  has  called  special  attention  to  the  value  of  this 
sugar  as  a  substitute  for  milk  and  cane  sugar  in  conditions  of  intestinal 
fermentation.  It  is  more  easily  assimilated  and  more  rapidly  absorbed 
than  lactose  or  saccharose  and  it  may  be  taken  therefore  by  the  infant  in 
larger  quantities  without  producing  sugar  fermentation.  The  ferments 
which  convert  milk  sugar  and  cane  sugar  occur  exclusively  in  the  intestinal 
canal,  so  that  if  this  digestive  process  is  not  completed  in  the  intestinal 
tract  the  partially  converted  sugars  may  be  absorbed  and  produce  a  sugar 
intoxication.  While,  on  the  other  hand,  the  ferment  which  converts  maltose 
occurs  not  only  in  the  intestinal  canal,  but  in  other  parts  of  the  body,  so 
that,  if  partially  converted  maltose  is  absorbed,  sugar  intoxication  is,  as  a 
rule,  prevented  by  the  further  action  of  this  ferment  after  this  form  of 
sugar  has  been  absorbed,  and  this  fact  may  partially  explain  the  fact  that 
the  feeding  of  maltose  rarely  produces  sugar  in  the  urine. 

Maltose  is  especially  indicated  in  the  feeding  of  very  young  and  deli- 
cate infants,  and  in  all  cases  where  either  milk  or  cane  sugar  has  produced 
intestinal  fermentation  and  sugar  intoxication.  In  the  feeding  of  maltose 
it  has  been  found  advisable  to  combine  it  with  about  equal  parts  of  dextrin. 
In  Germany,  and  later  in  this  country,  "Soxhlet's  Nahrzucker"  (which  con- 
tains maltose  52.44  per  cent.,  dextrin  41.26  per  cent.,  and  sodium  chlorid 
2  per  cent.)  has  been  largely  used.  Mead's  Dextri-Maltose  (malt  sugar), 
which  contains  about  equal  parts  of  dextrin  and  maltose,  is  a  similar 
preparation  which  may  be  used  instead  of  milk  sugar  or  cane  sugar  for 
modifying  milk  mixtures.  These  dextri-maltose  preparations  have  about 
the  same  caloric  value  as  milk  sugar,  but,  according  to  the  experiments  of 
Reuss,  Grosz  and  others,  their  relative  absorption  per  kilogram  of  body 


126  ARTIFICIAL  FEEDING  OF  INFANTS 

vvc.i.^ht  as  conipaml  with  milk  sugar  and  cane  sugar  is  as  7.7  to  3.1  grams. 
Mellin's  food  is  a  proprietary  maltose  dextrin  mixture  containing  three  or 
four  times  as  much  maltose  as  dextrin. 

Cereal  Decoctions.— Cereal  decoctions  such  as  barley,  oatmeal  and  rice- 
water  may  be  prepared  by  adding  a  slightly  rounded  tablespoonful  (I/2 
ounce)  of  barley  flour,  oatmeal  or  cracked  rice  to  a  pint  of  water  and  boil- 
ing for  thirty  or  forty  minutes,  and  then  adding  hot  water  to  the  mixtures 
to  supply  the  loss  from  evaporation,  so  that  the  cereal  decoctions  will  repre- 
sent a  pint  of  fluid  for  every  tablespoonful  of  the  cereal  used.  This  makes 
approximately  a  3  per  cent,  starch  mixture.  These  cereal  decoctions,  es- 
pecially barley  water,  have  been  strongly  recommended  by  Jacobi  for  many 
decades  and  are  now  very  generally  used  by  the  medical  profession.  They 
serve  the  double  purpose  of  furnishing  an  easily  digested  carbohydrate  food 
and  of  causing  the  casein  to  be  precipitated  in  fine  curds. 

Dextrinized  Gruels.— Dextrinized  gruels  are  made  by  adding  to  one  pint 
of  a  lukewarm  cereal  decoction,  such  as  barley  water,  one  tablespoonful  of 
one  of  the  thick  malt  extracts  such  as  maltine  or  maltzyme,  and,  after  five 
or  ten  minutes  of  stirring,  the  mixture  is  brought  to  a  boil.  Dextrinized 
gruels  contain  a  variable  amount  of  starch,  dextrin  and  maltose.  If  the 
dextrinizing  process  lasts  longer  than  thirty  minutes  all  the  starch  is  con- 
verted into  dextrin  and  maltose.  TCxperience  has  taught  that  a  cereal 
decoction  in  which  about  one-half  the  starch  is  converted  into  dextrin 
and  one-half  into  maltose,  offers  one  of  the  best  carbohydrate  mixtures  for 
infant  feeding,  and  this  result  can  be  approximately  obtained  by  dextrin- 
izing the  cereal  decoction  for  ten  minutes.  Dextrinized  gruels  prepared 
in  this  way  are  especially  adapted  to  furnish  young  and  delicate  infants 
with  a  carbohydrate  food  which  is  more  easily  digested  and  assimilated 
than  the  unmalted  cereal  decoctions.  The  old-fashioned  "flour  ball"  is 
prepared  by  tying  in  a  cloth  a  ball  of  wheat  flour  four  or  five  inches  in 
diameter,  suspending  it  in  boiling  water  five  or  six  hours  and  then  un- 
covering and  drying  the  flour.  The  starch  by  this  process  is  partly  con- 
verted into  dextrin.  One  tablespoonful  of  this  partially  dextrinized  flour 
when  mixed  and  boiled  in  one  pint  of  water  makes  a  very  good  carbohydrate 
mixture  for  modifying  cow's  milk. 

Condensed  Milk. — Condensed  milk  is  prepared  by  evaporating  cow's 
milk  about  one-fourth  in  volume.  It  is  preserved  by  the  addition  of  con- 
siderable quantities  of  cane  sugar — five  or  six  ounces  to  the  pint. 

The  composition  of  condensed  milk  is  shown  in  the  following  table 
from  Holt : 


Condensed 
Milk 

With  6  Parts  of 
Water  Added 

With  12  Parts  of 
Water  Added 

With  18  Parts  of 
Water  Added 

Fat 

Per  Cent. 
6.94 
8.43 

50.69 

1.39 
31.30 

Per  Cent. 
0.99 
1.20 

7.23 

0.17 
90.49 

Per  Cent. 
0.53 
0.65 

3.90 

0.10 
94.82 

Per  Cent. 
0  36 

Proteins 

0  44 

a„„.,  (Cane  40.44  1 

S"«"lMilk  10.25  f 

Salts 

2.67 

0.07 
96.46 

Water 

CARBOHYDRATES  127 

An  examination  of  the  percentages  given  in  this  table  shows  that  con- 
densed milk  is  not  a  properly  balanced  food  for  infant  feeding.  It  is 
notably  deficient  in  fats  and  proteins  and  contains  too  much  sugar,  so  that 
infants  fed  exclusively  upon  this  food  for  any  length  of  time  must  suffer 
more  or  less  seriously  from  nutritional  disturbances.  Condensed  milk 
babies  have  feeble  powers  of  resistance.  Their  teeth  and  bony  skeleton 
are  slowly  and  imperfectly  developed  and  they  are  commonly  fat,  flabby, 
rachitic  and  anemic.  But  notwithstanding  the  fact  that  the  long-continued 
use  of  condensed  milk  almost  invariably  produces  more  or  less  serious  mal- 
nutrition it  is  a  very  valuable  temporary  food  for  infants  under  certain 
conditions.  Its  advantages  are  that  it  is  easily  digested,  sterile,  cheap, 
easily  prepared,  and  easily  cared  for.  It  is  therefore  of  great  value  among 
the  poor  of  our  large  cities  who  cannot  afford  to  buy  clean  cow's  milk  and 
who  have  not  the  facilities  for  keeping  cow's  milk  clean  and  wholesome, 
even  if  it  were  furnished  to  them.  Thousands  of  infants  in  our  large 
cities  are  carried  through  the  summer  months  on  condensed  milk  who 
would  have  died  from  gastroenteric  troubles  if  their  mothers  had  been  com- 
pelled to  feed  them  upon  such  cow's  milk  as  they  could  procure,  and  these 
rachitic,  malnourished  babies,  who  have  passed  through  the  crisis  of  their 
existence  on  condensed  milk,  as  the  cooler  weather  comes  may  gradually 
overcome  these  malnutritions  by  the  addition  to  their  diet  of  more  whole- 
some food.  In  the  care  of  condensed  milk  babies  the  physician,  realizing 
the  importance  from  a  nutritional  standpoint  of  substituting  cow's  milk  for 
this  food,  too  often  makes  the  change  more  rapidly  than  the  child's  digestive 
capacity  will  permit  and  thereby  adds  a  gastrointestinal  disturbance  to  the 
malnutrition.  When  it  is  practicable  these  infants  should  have  cow's  milk 
added  very  gradually  to  the  condensed  milk  mixture  so  that  it  may  in  time 
gradually  displace  the  condensed  milk  mixture  without  disturbing  the  in- 
fant's digestive  capacity. 

PROPRIETARY  FOODS 

Nestle's  Food. — Nestle's  food  is  one  of  the  most  easily  digested  of  the 
proprietary  milk  foods.  It  is  a  valuable  temporary  substitute  for  cow's  milk 
in  infants  suffering  from  acute  gastrointestinal  disturbances.  Nestle's  food 
is  also  one  of  the  worst  of  the  proprietary  foods  for  continuous  administra- 
tion. Its  long-continued  use  as  the  sole  article  of  diet  very  commonly  pro- 
duces severe  forms  of  rickets  and  scurvy.  Chittenden's  analysis  of  Nestle's 
food,  prepared  according  to  directions  for  infants  of  six  months,  shows  that 
this  mixture  has  only  0.81  per  cent,  of  albuminoids  and  0.36  per  cent,  of 
fat.  This  mar-ked  deficiency  in  fat  and  protein  renders  it  quite  unfit  to 
serve  the  nutritional  demands  of  the  infant  for  any  great  length  of  time. 
When  Nestle's  food  is  used  as  a  substitute  for  milk  mixtures  in  the  gastro- 
intestinal disturbances  of  infancy  it  should,  as  soon  as  the  condition  of  the 
gastrointestinal  canal  will  permit,  have  added  to  it  small  quantities  of  milk, 
and  as  the  child  convalesces  the  milk  is  slowly  increased  and  the  Nestle's 
10 


128  ARTIFICIAL  FEEDING  OF  IXFAXTS 

food  mixture  diminished,  imtil  a  modified  milk  formula  replaces  the  ISTestle's 
food.  When  for  any  reason  it  is  necessary  to  continue  Xestle's  food  for 
any  length  of  time  and  cow's  milk  cannot  be  added  to  the  mixture,  the 
infant  should  be  given  as  supplemental  foods  orange  juice  and  codliver  oil. 
By  these  additions  it  may  be  possible  to  prevent  the  scurvy  and  rickets 
which  otherwise  might  follow. 

Malted  Milk.— Malted  milk  is  a  proprietary  milk  food  which,  like 
Nestle's  food  and  condensed  milk,  is  very  poor  in  fat  and  in  the  total  quan- 
tity of  solid  matter  it  contains.  It  is  therefore  not  to  be  recommended  as 
an  exclusive  food  for  infants.  It  may,  however,  be  used  as  a  temporary 
substitute  for  milk  as  in  traveling  or  where  for  any  other  reason  cow's 
milk  is  not  available.  It  is,  like  condensed  milk,  very  extensively  used 
among  the  poor  of  our  large  cities,  because  it  is  easily  digested,  easily  pre- 
pared, and  serves  the  purpose  of  tiding  the  infant  over  the  hot  summer 
months. 


CHITTENDEir's    TABLE 


Composition  of  some  infants  foods  as  prepared  for  the  nursing-bottle  in  comparison  xcith  mother's  milk. 
Prepared  according  to  directions  for  infants  of  stx  months. 


Mother's 

Malted 

Milk 

Milk 

1031 

1025 

86.73 

92.47 

13.26 

7.43 

0.20 

0.29 

2.00 

1.15 

2.00 

1.15 

0 

trace 

4.13 

0.68 

6.93 

1.18 

0 

0 

0 

3.28 

0 

0.92 

0 

0 

0 

0 

alkaline 

alkaline 

Nestle's 
Milk  Food 


Imperial 
Granum 


Mellin's 
Food 


Peptogenic 
Powder 


Specific  gravity 

Water 

Total  solid  matter. . . 

Inorganic  salts 

Total  albuminoids. .  . 
Soluble  albuminoids . 
Insoluble  albuminoids 

Fat 

Milk  sugar 

Cane  sugar 

Maltose 

Dextrin 

Soluble  starch 

Starch 

Reaction 


1024 
92.76 
7.24 
0.13 
0.81 
0.36 
0.45 
0.36 
0.84 
2.57 
trace 

0.44 

1.99 
alkaline 


1025 
91.53 
8.47 
0.34 
2.15 
1.67 
0.48 
1.64 
2.71 
0 
trace 

0.58  \ 


1.22 
alkaline 


1031 

1032 

88.00 

86.03 

12.00 

13.97 

0.47 

0.26 

2.62 

2.09 

2.62 

2.09 

0 

0 

2.89 

4.38 

3.25 

7.26 

0 

0 

2.20 

0 

0.53 

0 

0 

0 

0 

0 

alkaline 

alkaline 

ALBUMIN  WATER 

Albumin  water  is  prepared  by  adding  the  white  of  an  egg  to  8  ounces 
of  boiled  water  which  may  be  slightly  flavored  with  salt.  This  food  is  very 
largely  used  in  acute  gastrointestinal  disturbances  as  a  temporary  substitute 
for  cow's  milk  where  the  latter  is  contraindicated.  The  fact  that  it  has 
been  used  in  this  way  for  many  years  and  still  remains  a  favorite  with  the 
medical  profession  is  evidence  that  it  is  a  valuable  substitute  food  in  the 
treatment  of  these  conditions.  In  my  experience,  however,  albumin  water 
has  not  acted  as  kindly  in  these  conditions  as  barley  water  and  other  sub- 
stitutes that  are  used  for  the  same  purpose.  It  is  valuable  as  a  food  in 
the  regular  diet  of  infants  over  eight  months  of  age. 


VALUE  OF  PERCENTAGE  FEEDING        129 

MEAT  PREPARATIONS 

Beef  Juice. — Fresh  beef  juice  may  be  prepared  by  slightly  singeing  a 
beefsteak  on  both  sides  and  then  cutting  it  into  small  pieces  about  half  an 
inch  square  and  expressing  the  juice  with  a  meat  press.  The  singeing  of 
the  beefsteak  answers  the  double  purpose  of  partially  sterilizing  the  steak 
and  of  giving  to  the  expressed  juice  the  flavor  of  cooked  meat.  When  pre- 
pared in  this  way  beef  juice  according  to  Holt  has  the  following  com- 
position : 

Proteins 2.90  per  cent. 

Fat 0.60  per  cent. 

Extractives 3.40  per  cent. 

Salts 0.20  per  cent. 

Water 92.90  per  cent. 

It  will  thus  be  seen  that  beef  juice  contains  approximately  3  per  cent, 
of  albumin.  It  is  a  valuable  food  for  infants  during  the  second  year  of  life 
and  may  be  given,  if  necessary,  as  a  supplemental  food  during  the  last  three 
months  of  the  first  year.  It  is  also  a  valuable  substitute  food  in  all  gastro- 
intestinal disorders  where  milk  is  contraindicated.  It  is  not  only  easily 
cared  for  by  the  digestive  organs  of  the  infant,  but  is  a  stimulant  and  food 
of  great  value  in  many  cases  where  other  foods  are  but  poorly  tolerated. 

Broths. — Broths  made  from  mutton,  beef,  and  chicken  to  which  a  cereal 
has  been  added,  in  the  proportion  of  one  tablespoonful  to  the  pint  of  broth, 
are  valuable  foods  which  enter  into  the  dietary  of  the  child  during  the 
second  year  of  life.  The  plain  animal  broths  made  from  beef  and  mutton, 
and  from  which  the  fat  has  been  carefully  skimmed,  are  useful  substitute 
foods  in  the  gastrointestinal  disturbances  of  infancy  where  milk  is  contra- 
indicated.  These  broths  contain  only  about  1  per  cent,  of  protein  and 
therefore  are  of  little  value  as  foods,  but  they  are  stimulating  and  satisfy- 
ing and  may  be  used  temporarily  during  the  starving  process  in  all  condi- 
tions of  infancy  where  it  is  necessary  to  temporarily  withhold  other  foods. 


CHAPTER  XIV 
AETIFICIAL    FEEDING 

VALUE  OF  PERCENTAGE  FEEDING 

The  percentage  composition  of  human  milk  is  of  great  interest  in  that 
it  gives  the  actual  and  relative  amounts  of  fat,  proteins,  sugar  and  salts 
which  the  ideal  infant  food  contains.  There  is  no  doubt  but  that  the 
various  ingredients  of  human  milk  are  combined  in  actual  and  relative 
amounts  to  suit  the  digestive  capacity  and  the  nutritional  demands  of  the 
human  infant.  Neither  is  there  any  doubt  but  that  the  formula  of  human 
milk  would  be  our  best  guide  in  making  an  artificial  food  for  infants  if  the 


130  ARTIFICIAL  FEEDING 

various  ingredients  of  cow's  milk  resembled  in  every  particular  those  of 
human  milk.  Both  of  these  statements  are  self-evident  facts,  and  upon 
them  the  American  school  of  pediatricians  has  made  percentage  feeding 
the  underlying  principle  in  the  artificial  feeding  of  infants.  By  percentage 
feeding  is  meant  that  the  percentages  of  the  chief  ingredients  of  an  infant 
food  shall  be  combined  in  proper  proportions  to  meet  the  nutritional  de- 
mands and  suit  the  digestive  capacity  of  the  individual  infant.  In  making 
an  artificial  food  if  one  had  only  to  consider  the  nutritional  demands  of  an 
infant  it  would  be  an  easy  matter  to  write  out  a  food  formula  conforming 
in  the  percentages  of  its  principal  ingredients  to  human  milk,  but  as  one 
has  also  to  consider  the  food  idiosyncrasies  as  well  as  the  digestive  and 
assimilative  capacity  of  the  individual  infant  for  a  food  whose  principal 
ingredients  are  derived  from  cow's  milk  and  which  are,  as  pointed  out  in 
another  chapter,  chemically,  biologically,  and  pliysiologically  different  from 
the  ingredients  of  human  milk,  it  follows  that  the  percentage  formula  of  an 
infant  food  to  meet  these  conditions  must  differ  materially  from  woman's 
milk.  An  artificial  food  therefore,  under  the  percentage  or  any  other  method 
of  feeding,  must  be  constructed  primarily  to  conform  to  the  digestive  ca- 
pacity of  the  infant,  but  in  conforming  to  this  standard  the  various  in- 
gredients of  the  food  mixture  should  not  differ  in  their  relative  proportions 
BO  widely  from  the  composition  of  mother's  milk  as  to  produce  a  partial 
starvation  in  either  protein,  fat,  carbohydrates  or  salts.  If  both  the  diges- 
tive capacity  and  the  nutritional  demands  of  the  infant  are  considered  in 
the  making  of  an  artificial  food,  more  or  less  accurate  relative  percentage 
values  must  be  maintained  and  experience  has  demonstrated  that  this  is  a 
practical  and  scientific  method  of  feeding.  The  only  danger  in  this  method 
is  that  the  physician  may  be  so  impressed  with  its  accuracy  that  he  may 
give  more  attention  to  his  method  than  he  does  to  the  digestive  capacity 
and  nutritional  demands  of  the  individual  infant. 

CALORIC  STANDARD 

The  caloric  value  of  woman's  milk  is  of  great  interest  in  that  it  fur- 
nishes us  with  an  accurate  standard  of  the  food  value  of  the  ideal  infant 
food. 

A  calorie  is  the  amount  of  heat  required  to  raise  the  temperature  of  one 
kilogram  of  water  1°  C;  this  is  the  unit  of  value  by  which  the  heat-  or 
energy-producing  values  of  various  foods  are  measured.  The  ingredients  of 
milk  have  the  following  caloric  values : 

1  gram  of  protein  will  produce 4.1  calories 

1  gram  of  fat  will  produce 9.1  calories 

1  gram  of  sugar  will  produce 4.1  calories 

Spiegelberg  says:  "From  calculations  made  by  different  authors  it  can 
be  said  that  a  strong  breast-fed  baby  in  the  first  two  months  consumes  daily 
about  one-fifth  of  its  body  weight  of  milk.     In  the  second  quarter  of  the 


CALOEIC    STANDARD  131 

year  this  diminishes  to  one-sixth  or  one-seventh.  In  the  latter  months  of 
the  year  to  one-eighth  or  one-ninth  of  the  body  weight.  A  two-months-old 
child  therefore  weighing  4,000  grams  would  take  one-fifth  of  4,000 — that 
is  to  say,  800  grams  each  day.  A  seven-months-old  child  weighing  7,000 
grams  would  take  1,000  grams." 

These  values  accord  with  those  given  by  Heubner,  that  infants  consume 
daily  during  the  first  three  months  an  amount  of  milk  equal  to  45  calories 
per  pound  of  body  weight ;  during  the  next  quarter  about  43  calories ;  dur- 
ing the  third  quarter  about  38  calories,  and  during  the  last  quarter  of  the 
first  year  of  life  about  34  calories.  In  general  terms  therefore  one  may  say 
that  an  infant's  food  should  have  a  caloric  value  of  40  for  every  pound  of 
body  weight.  A  twenty-pound  infant  would  require  800  calories  in  twenty- 
four  hours.  In  young  infants  one  may  have  to  slightly  increase  and  in  older 
infants  slightly  diminish  these  values. 

To  determine  the  number  of  calories  in  a  food  mixture  multiply  the 
number  of  ounces  of  each  ingredient  used  in  twenty-four  hours  by  the  fuel 
value  of  an  ounce  of  this  food,  add  the  products  and  the  sum  will  represent 
the  caloric  value  of  the  food.  The  following  table  shows  the  energy  quo- 
tients of  different  materials  used  in  infant  feeding : 

1  qt.  of  whole    milk    contains 690  calories 

1  qt.  of  %  whole  milk  contains     460  calories 

1  qt.  of  Vo  whole  milk  contains     350  calories 

1  qt.  of  %  whole  milk  contains     230  calories 

1  qt.  of  buttermilk   contains    410  calories 

1  qt.  of  ordinary   skimmed   milk   contains 410  calories 

1  qt.  of  fat-free  skimmed  milk  contains 320  calories 

1  oz.  of  fat-free  skimmed  milk  contains 10  calories 

1  oz.  of  ordinary   skimmed   milk   contains 13  calories 

1  oz.  of  whole    milk    contains 21  calories 

1  oz.  of  buttermilk   contains    13  calories 

1  oz.  of     7  per  cent,  top  milk  contains     31  calories 

1  oz.  of  10  per  cent,  top  milk  contains    39  calories 

1  oz.  of  16  per  cent,  cream   contains    54  calories 

1  oz.  of  carbohydrate  contains   120  calories 

From  this  table  it  will  be  easy  to  determine  the  caloric  value  of  any 
food  mixture.    Take  for  example  the  following : 

Top    milk    7    per   cent,    fat     16  oz.  =:    31x16^496  calories 

Sugar    of    milk 2  oz.  z=  120  X    2  =  240  calories 

Water    13  oz. 

31  oz.  =  736  calories 

The  value  of  the  above  food  formula  is  therefore  736  calories,  and, 
since  40  calories  are  required  for  each  pound  of  body  weight,  if  we  divide 
736  by  40  we  find  that  the  above  food  mixture  has  the  requisite  number  of 
calories  to  feed  an  18-pound  baby  twenty-four  hours. 

The  calorimetric  standard  of  the  German  school  is  the  only  accurate 
method  we  possess  for  determining  the  amount  of  food  an  infant  should 
take  in  twentv-four  hours,  and  the  importance  of  utilizing  this  standard 


132  ARTIFICIAL  FEEDING 

to  prevent  the  over-  or  underfeeding  of  infants  should  be  insisted  upon,  as 
by  this  standard  alone  can  we  be  sure,  in  varying  the  different  ingredients  of 
an  artificial  food  mixture  to  suit  the  digestive  capacity  of  the  infant,  that 
we  are  giving  it  a  food  the  energy  equivalent  of  which  will  accurately 
satisfy  all  the  demands  of  the  body.  The  calorimetric  standard,  however, 
must  not  for  a  moment  be  considered  as  a  method  of  feeding  or  as  the 
sole  or  all-important  principle  upon  which  a  baby  food  is  to  be  constructed. 
It  is  simply  a  standard  which  prevents  the  over-  or  underfeeding  of  infants 
by  whatever  method  we  adopt.  An  infant  may  be  fed  the  proper  number  of 
calories  of  an  ill-balanced  food,  such  as  condensed  milk  and  the  various 
patent  milk  foods,  and  yet  suffer  serious  nutritional  disturbances  because 
of  the  relatively  low  percentages  of  fats  and  proteins  in  these  foods.  This 
illustration  emphasizes  the  fact  that  the  proteins,  fat  and  carbohydrates, 
apart  from  their  caloric  values,  have  definite  and  distinct  purposes  to  serve 
in  supplying  the  nutritional  demands  of  the  infant.  It  follows  therefore 
that  the  percentage  method  of  feeding,  which  gives  to  the  infant  the  rela- 
tive quantities  of  fat,  carbohydrates,  proteins  and  salts  it  needs,  must  ever 
remain  the  basis  of  scientific  infant  feeding,  and  that  in  using  this  method 
one  should,  to  secure  fairly  accurate  quantities,  conform,  within  certain 
limits,  to  the  calorimetric  standard,  and  should,  to  prevent  or  correct  gas- 
trointestinal disturbances,  change  the  percentages  of  the  various  food  in- 
gredients to  conform  to  the  digestive  capacity  and  food  idiosyncrasies  of 
the  individual  infant. 

PRINCIPLES  OF  ARTIFICIAL  FEEDING 

Success  in  infant  feeding  depends  not  upon  the  particular  method  used, 
but  upon  the  intelligence,  the  experience  and  the  know^ledge  of  the  under- 
lying principles  of  infant  feeding  which  the  physician  possesses.  Methods 
of  infant  feeding  are  to  experienced  physicians  what  tools  are  to  artisans. 
As  one  artisan  may  be  more  skilled  in  the  use  of  a  certain  tool  than  an- 
other, so  one  physician  may  be  more  skilled  in  the  use  of  a  certain  method 
of  feeding  than  another.  The  principles  which  underlie  the  art  of  infant 
feeding  are,  therefore,  so  much  more  important  to  success  than  are  indi- 
vidual methods  that  one  is  justified  in  trying  to  so  formulate  these  principles 
that  they  may  form  the  nucleus  around  which  the  young  physician  may 
build  the  clinical  experience  which  will  enable  him  more  intelligently  to 
use  whatever  method  of  infant  feeding  he  may  choose. 

The  principles  underlying  the  artificial  feeding  of  infants  do  not  and 
possibly  never  will  constitute  an  exact  science,  since  the  capacities  and 
idiosyncrasies  of  infants  in  the  digestion  and  assimilation  of  protein,  fat, 
carbohydrates  and  salts  cannot  be  foretold.  There  must  therefore  always 
remain  certain  difficulties  to  be  overcome  by  experimentation.  These  experi- 
ments, however,  should  be  carried  along  certain  lines  derived  from  clinical 
experience.  The  following  principles  derived  from  this  source  will  be  of 
value  in  the  artificial  feeding  of  infants. 


PRINCIPLES  OF  ARTIFICIAL  FEEDING  133 

I.  Clean  milk  is  absolutely  necessary  to  success  in  infant  feeding.  Un- 
clean milk  cannot  by  any  process  be  made  into  a  safe  and  wholesome  infant 
food;  if  pasteurization  is  necessary  clean  milk  must  be  used  to  start  with. 
This  principle  of  infant  feeding  is  absolutely  essential  and  is  much  more 
important  to  success  than  methods  of  modification.  Cream  is  always  much 
more  contaminated  with  bacteria  than  milk  of  the  same  age,  and  com- 
mercial cream,  which  is  from  twelve  to  twenty-four  hours  older  than  milk, 
contains  a  bacterial  content  so  large  that  it  is  unsafe  for  infant  feeding. 
If  it  be  necessary  to  increase  the  amount  of  fat  in  an  infant's  food  this 
may  be  done  by  taking  a  certain  percentage  from  the  top  of  clean  milk. 
In  this  way  one  obtains  a  clean,  wholesome  cream.  The  formulas  for  the 
making  of  cream  mixtures  which  are  so  widely  spread  among  the  laity  are 
the  cause  of  no  small  part  of  the  digestive  disturbances  which  occur  in 
infants.  The  milk  used  in  infant  feeding-  should  come  preferably  from 
common  cows  (Holstein  and  Ayrshire)  rather  than  from  highly  bred  ones 
of  the  Alderney  or  Jersey  variety.  The  milk  from  highly  bred  cows  con- 
tains too  high  a  percentage  of  fat  and  this  fat  is  not  as  digestible  as  that 
found  in  the  milk  of  the  common  cow. 

II.  The  infant  should  be  placed  upon  a  food  formula  which  contains 
about  the  requisite  number  of  calories.  If,  however,  it  fails  to  thrive  and 
the  gastrointestinal  conditions  remain  normal  the  number  of  calories  (the 
strength  or  quantity  of  the  food)  should  be  increased.  An  infant  should 
never  he  allowed  to  starve  because  it  fails  to  thrive  on  the  number  of  calo- 
ries which  a  mathematical  calculation  awards  it.  On  the  other  hand,  if  an 
infant  has  become  ill  on  a  food  formula  one  of  the  first  inquiries  to  make 
is  as  to  whether  it  is  being  overfed  in  calories. 

III.  Overfeeding,  not  only  in  the  number  of  calories  but  also  in  the 
number  of  ounces  given,  is  the  cause  of  many  failures  in  infant  feeding. 
It  is  most  important  therefore  that  the  number  of  ounces  taken  by  the  indi- 
vidual infant  should  be  adjusted  to  suit  the  capacity  of  its  stomach.  To 
overfeed  in  ounces  given  will  cause  gastric  and  intestinal  disturbance  or 
will  result  in  dilatation  of  the  stomach  with  chronic  gastric  indigestion 
which  months  of  careful  feeding  are  required  to  overcome.  To  give  an  in- 
fant all  it  will  take  is  a  very  common  practice  and  one  fraught  with  the 
gravest  dangers.  The  capacity  of  the  stomach  of  the  average  newly  born  in- 
fant is  about  one  ounce  and  in  premature  infants  it  is  less.  The  stomach 
grows  in  size  rapidly  for  the  first  four  months,  at  which  time  its  capacity 
is  about  5  or  6  ounces.  After  the  fifth  month  the  stomach  develops  less 
rapidly,  so  that  at  ten  months  it  should  hold  about  9  or  10  ounces.  At 
one  year  of  age  the  stomach  should  hold  from  10  to  12  ounces.  Under  one 
year  of  age  the  total  quantity  of  liquid  given  in  twenty-four  hours  should 
not  exceed  40  or  45  ounces.  In  under-  or  oversized  infants  the  number  of 
ounces  given  may  be  slightly  increased  or  diminished  to  suit  the  weight  of 
the  child.  Overfeeding,  in  the  number  of  calories  given,  is  also  one  of  the 
most  common  causes  of  digestive  disturbance  in  infancy.  But  under  these 
conditions  the  overfeeding  does  not  always  refer  to  an  excessive  fuel  value 


134  ARTIFICIAL  FEEDING 

of  all  of  the  ingredients  of  the  food,  but  may  be  due  to  a  great  preponder- 
ance of  the  carbohydrates,  fats  or  whey  salts.  The  important  fact  to  bear 
in  mind  is  that  infants  may  be  made  ill  with  a  perfectly  wholesome  food 
if  given  in  excessive  quantities  and  the  overfeeding  may  comprehend  an 
excessive  quantity  of  all  or  of  any  one  of  the  ingredients  of  its  food. 

IV.  Artificially  fed  infants  should  be  given  their  food  at  regular  inter- 
vals. This  is  absolutely  necessary  to  obtain  the  best  results.  The  infant 
must  be  fed  not  only  regularly  but  the  interval  between  the  feedings  must 
be  carefully  adjusted  to  suit  its  age,  weight  and  digestive  capacity.  From 
the  end  of  the  first  week  to  the  end  of  the  fourth  week  a  two-hour  interval 
should  be  maintained ;  during  the  second  and  third  months  a  two-and-a-half- 
hour  interval ;  from  the  third  to  the  sixth  month  a  three-hour  interval,  and 
thereafter  a  four-hour  interval.  These  periods  should  be  observed  with 
the  strictest  regularity,  between  the  hours  of  6  A.  M.  and  10  P.  M.,  until 
the  child  is  five  months  of  age,  and  between  the  hours  of  10  P.  M.  and 
6  A.  M.  a  much  longer  interval  should  be  observed.  After  the  fifth  month 
the  night  feeding  should  be  discontinued.  When  eight  months  of  age  the 
infant  should  have  but  four  feedings  in  twenty-four  hours,  beginning  at 
6  or  7  A.  M.  and  finishing  at  6  or  7  P.  M. 

V.  Eest  for  the  nervous  system  is  a  most  important  aid  to  infantile 
digestion.  Infants  should  be  taught  to  lie  quietly  without  coddling  and 
should  live  in  quiet  surroundings,  so  that  they  may  get  the  full  amount  of 
sleep  due  them.  The  immature  nervous  system  of  the  infant,  when  excited 
by  outside  causes,  exerts  a  most  profound  influence  over  the  digestive 
organs. 

VI.  Fresh  air  is  perhaps  the  most  important  outside  aid  in  improving 
the  digestive  capacity  of  the  infant.  As  soon  as  possible,  after  the  first 
month  in  winter  and  almost  from  birth  in  summer,  it  should  be  taught  to 
live  and  sleep  during  the  greater  portion  of  the  day  in  the  open  air.  North- 
rup  has  laid  great  stress  upon  the  fact  that  it  is  quite  as  important  for  suc- 
cess in  infant  feeding  "to  modify  the  baby"  by  rest  and  fresh  air  as  it  is  to 
modify  the  food. 

VII.  The  infant's  food  should  contain  fat,  protein  and  carbohydrates 
in  fairly  accurate  percentages;  that  is  to  say,  these  ingredients  should  be 
combined  in  such  relative  quantities  as  will  best  meet  the  nutritional  de- 
mands of  the  infant.  Should  it  be  necessary  in  the  treatment  of  digestive 
disturbances  to  change  the  food  formula  by  markedly  cutting  down  either 
the  fat  or  the  protein,  the  physician  should  be  most  careful  to  see  that  the 
permanent  formula  adopted  during  convalescence  should  return  in  fat  and 
protein  as  nearly  as  possible  to  the  original  formula.  The  necessity  for 
this  lies  in  the  fact  that  no  other  food  ingredient  can  take  the  place  of 
protein,  and  that  while  the  carbohydrates  may  for  a  time  partially  substi- 
tute for  fat,  the  continued  use  of  very  low  fat  percentages  will  in  time  pro- 
duce serious  nutritional  disturbances.  The  partial  starvation  of  infants 
in  protein,  fat,  and  salts  results  in  rickets,  scurvy,  anemia  and  other  mal- 
nutritions.   These  ingredients  should  therefore,  within  the  limitations  of  the 


HOME   MODIFICATION   OF    MILK  135 

child's  digestive  capacity,  be  gradually  restored  to  the  quantities  which  the 
age  and  weight  of  the  child  demand. 

yill.  The  fat  of  cow's  milk  is  not  as  readily  digested  as  that  of  hu- 
man milk.  It  is  therefore  wise  to  place  the  percentages  of  fat  in  modified 
milk  mixtures  for  young  infants  much  lower  than  it  is  in  human  milk. 
Excess  of  fat  is  one  of  the  most  common  early  causes  of  indigestion.  To 
correct  this  condition  the  first  trial  change  to  be  made  in  the  food  formula 
is  a  reduction  of  fat  (cream)  and  a  corresponding  increase,  in  calories,  of 
the  carbohydrates.  The  indications  for  this  change  are  strengthened  if  the 
infant  has  the  following  symptoms:  Habitual  regurgitation,  constipation 
with  gray,  dry  stools,  or  loose  movements  with  small,  soft  curds  and  an 
irritating  urine  with  an  ammoniacal  odor, 

IX.  The  casein  of  cow's  milk  may  be  a  cause  of  indigestion.  If,  there- 
fore, the  reduction  of  fat  fails  to  correct  the  trouble  an  effort  should 
be  made  to  prevent  the  coagulation  of  casein  in  the  stomach,  by  adding  to 
the  food  sodium  citrate,  alkalies  or  cereal  decoctions,  or  perhaps  by  boiling 
the  milk.  If  these  measures  fail  the  casein  may  be  diminished  and  the  whey 
proteins  added  to  make  up  the  deficiency.  When  the  cause  of  the  trouble  is 
thus  righted  the  fat  and  the  protein  may  be  slowly  increased  to  the  original 
formula.  Casein  indigestion  is  indicated  by  large,  tough  curds,  putrid, 
loose,  brownish,  alkaline  stools,  fever  and  other  constitutional  symptoms. 

X.  The  carbohydrates,  including  the  sugars,  are  the  most  easily  di- 
gested of  the  food  ingredients  of  a  modified  milk  mixture,  and  for  this 
reason  they  are  not  uncommonly  increased  at  the  expense  of  fat  and  pro- 
tein. Under  such  conditions  a  carbohydrate  indigestion  and  sugar  intoxica- 
tion may  result.  This  may  be  indicated  by  a  watery,  acid,  nonputrid 
diarrhea  which  produces  irritation  of  the  buttocks  and  which  is  frequently 
associated  with  fever,  severe  constitutional  symptoms,  much  gas  forma- 
tion and  intestinal  catarrh.  When  this  occurs  the  sugars  must  be  tem- 
porarily eliminated  from  the  diet  until  these  symptoms  subside  and  then 
a  different  carbohydrate  (sugar)  should  be  added,  preferably  one  that  con- 
tains a  large  percentage  of  maltose  and  dextrin,  since  they  are  less  liable 
to  produce  fermentation  than  any  of  the  other  sugars  or  starches. 

HOME  MODIFICATION  OF  MILK 

The  home  modification  of  milk  is  almost  universally  used  for  infant 
feeding.  The  term  "home  modification"  carries  with  it  no  definite  condi- 
tions for  the  modification  of  milk.  It  is  simply  a  general  term  used  to 
cover  all  methods  by  which  milk  is  modified  at  home  with  the  idea  of 
making  it  more  suitable  to  the  digestive  capacity  and  nutritional  demands 
of  the  infant.  Nearly  every  physician  of  experience  has  worked  out  for 
himself  a  plan  for  modifying  milk  which  his  clinical  experience  has  taught 
him  will  serve  his  purposes  better  than  any  other  that  he  has  been  able 
to  find,  and  nearly  every  author  offers  his  own  plan  for  the  home  modifica- 
tion of  milk  by  which  a  certain  degree  of  accuracy  in  percentage  feeding 


136 


ARTIFICIAL  FEEDING 


may  be  obtained.  This  state  of  affairs  proves  that  there  is  no  single  method 
which  outranks  all  others.  The  object  of  all  these  methods  is  to  give  the 
pliysician  certain  rules  of  tliumb  by  which  he  may  make  milk  formulas  con- 
taining definite  percentages  of  protein,  fat,  carbohydrates,  and  salts.  Nearly 
all  of  these  methods  of  feeding  are  more  or  less  complicated  in  that  they  are 
fornmlated  upon  the  idea  that  very  exact  percentages  of  protein,  fat,  carbo- 
hydrates, and  salts  are  necessary  to  obtain  good  results  in  infant  feeding,  and 
the  complications  of  the  various  methods  commonly  defeat  their  very  ob- 
jects, in  that  the  average  physician  will  not  take  the  time  or  trouble  to 
work  out  by  them  the  exact  percentages  of  the  ingredients  of  a  modified 
milk  mixture.  While  there  can  be  no  objection  to  accurate  percentages  in 
infant  feeding,  yet  the  experience  of  the  world  has  demonstrated  that  these 
accurate  percentages  are  not  absolutely  necessary  to  success,  and  that  on 
the  whole  infants  thrive  just  as  well  upon  a  milk  mixture  which  is  intelli- 
gently modified  so  that  protein,  fat,  carbohydrates,  and  salts  are  found  in 
fairly  definite  percentages  and  in  such  quantities  that  the  infant  will  not 
suffer  from  a  starvation  of  any  one  of  these  important  ingredients.  Largely 
as  a  result  of  the  complicated  methods  now  in  vogue, most  physicians  com- 
monly use  whole  milk  and  some  diluent  in  the  form  of  a  carbohydrate  food, 
and  upon  these  simple  mixtures  the  large  percentage  of  our  infantile  popu- 
lation is  now  thriving.  While  the  simplicity,  of  the  "whole  milk"  method 
of  modifying  food  has  made  it  popular,  there  is  no  question  but  that  much 
better  results  can  be  obtained  by  a  method  which  utilizes  top  milk  as  well 
as  whole  milk  in  the  preparation  of  infant  foods,  in  that  in  this  way  the 


36 
25 
24 
23 
22 
21 
20 
19 
18 

to  17 
O  16 

OI4 

0-13 

12 

II 

to 

9 
8 
7 
6 
S 


12342678910  12  14  16  18  20  22  24  26  28  30  32  34  36  38  40  42  44  46  48  50  52 
AGE  IN  WEEKS 
Fig.  21. — Weight  Chart  of  Artificially  Fed  Infant. 

fat  percentages  may  be  better  adapted  to  the  nutritional  demands  of  the 
infant. 

Percentage  feeding  may  be  greatly  simplified  and  its  efficacy,  as  I  be- 


HOME   MODIFICATION   OF    MILK 


137 


lieve,  not  materially  diminished  by  making  all  food  formulas  from  three 
ingredients,  viz. : 

I.  Whole  milk,  which  to  simplify  computations  one  may  assume  con- 
tains 4  per  cent,  of  fat,  4  per  cent,  of  protein,  and  4  per  cent,  of  carbohy- 
drate. 

II.  Top  milk  containing  7  per  cent,  cream,  obtained  by  taking  the  top 
half  of  the  milk  after  it  has  stood  for  two  hours.  This  contains  approxi- 
mately 7  per  cent,  fat,  4  per  cent,  protein,  and  4  per  cent  carbohydrate. 

III.  A  carbohydrate  solution  made  of  sugars  or  starches  containing 
one-half  ounce  of  carbohydrate  to  the  pint. 

In  infants  under  six  months  of  age,  because  of  the  greater  dilution  of 
the  milk,  the  7  per  cent,  top  milk  should  be  used,  so  as  not  to  get  too  low 
percentages  of  fat.  In  infants  over  six  months  of  age  whole  milk  may  be 
used. 

In  making  modified  milk  mixtures  from  these  ingredients  the  physi- 
cian should  be  guided  by  "the  principles  underlying  the  artificial  feeding  of 
infants,"  previously  outlined.  The  following  tables  show  how  these  ingre- 
dients may  be  combined  in  the  production  of  an  infant  food  which  will 
answer  all  practical  purposes,  that  is  to  say,  will  possess  the  proper  number 
of  calories,  will  contain  the  important  ingredients,  proteins,  fat,  and  car- 
bohydrates in  such  relative  and  absolute  quantities  that  the  nutritional  and 
digestive  demands  of  the  infant  will  be  satisfied  quite  as  well  as  by  more 
complicated  mixtures  in  which  the  percentages  of  protein,  fat,  and  carbo- 
hydrates are  worked  out  to  the  fraction  of  a  per  cent. 

Between  the  eighth  and  the  twelfth  month  the  food  of  the  average  well 
infant  outlined  in  this  table  is  to  be  supplemented  by  the  addition  of  orange 
juice,  raw  egg  albumin,  thick  cereal  gruels,  meat  juice,  and  meat  broths 
with  a  cereal  admixture,  but  these  foods,  with  the  exception  of  orange 


7  Per  Cent.  Top  Milk  Table 


5 

o 

•o 

a 

m 

N 

s 

■* 

h 

3 

o 

03 

bC 

a 

'i 

a 

.s 

1 
a 

o 

a 
a 
O 

"o 

"o 

"o 

*:> 

a 

•s 

0 

•£ 

3 

-0 

a 

Ci 

'i 

■■B 
•o 

t 

1 
1 

1 

0, 

1 

Q. 
O 

O 

O 

1 

■3 

0 

i 

0 

Q 

"o 

a 

a 

0 

I 

6 
"0 

M 

a 

S 

•E 
0 
■3 

2 
3 

■3 

< 

w 

O 

^ 

H 

H 

s 

pq 

'3 

t^ 

CM 

^ 

0 

0 

1  Wk.. 

7.5 

2 

2 

10 

20 

6 

1 

13 

2 

1 

6 

306 

300 

2  Wk3.. 

7.5 

2 

2 

10 

20 

6 

1 

13 

2 

1 

6 

306 

300 

3  Wks.. 

4  Wks.. 
2  Mo .  . 

8.0 
8.5 
10.75 

2}i 

3 

4 

2 

2H 

3 

9 

8 
7 

22}^ 

94. 

6,^ 
7 

k 

15 
16 

18 

2 
2 
2.2 

1.1 
1.1 
1.3 

5.6 
5.7 
5.5 

321 
352 
429 

320 
340 
430 

28 

9 

3  Mo.  . 

12.50 

5 

3 

7 

35 

lOH 

I'A 

23K 

2.1 

1.2 

5.5 

505 

500 

4  Mo.  . 

14 

5 

3 

7 

35 

nVi 

IH 

2234 

2.3 

1.3 

6.4 

565 

560 

6  Mo.  . 

15 

6 

3J^ 

6 

36 

13 

1% 

22 

2.5 

1.5 

6.5 

603 

600 

6  Mo.  . 

16 

6H 

334 

6 

39 

15 

VA 

23 

2.7 

1.5 

5.5 

645 

640 

138 


AirriFICIAL  FEEDING 
Whole   Milk   Table 


1 

I 
1 
1 

1 
s 

"3 
t 

0 
» 

a 

1 
1 

0 
1 

z 

10 

10 
9 

8 
7 
7 
7 
6 
6 
5 
5 
5 
5 
4 
4 

0 

.9 

a 

1 

! 

u 

1 
■0 

"S 
a 

V 

0 

U 

1 
ft 
0 

H 

0 

i 

CO 

1 

Boiled  Water,  Obs.  of 

"S 
0 

1 
s 

0 

1 

§ 

1 

■5; 
1 

t 
i 

1 

>> 

A 

\ 
1 

3 

"i 

0 

1 

1 

.2 
_o 
■«3 
0 

1  Wk. .  .  . 
2Wks... 

awks... 

4Wk3... 

2  Mo.... 

3  Mo.... 

4  Mo. . . . 

5  Mo... 

6  Mo.... 

7  Mo. . . . 

8  Mo. . . . 

9  Mo. . . . 

10  Mo.... 

11  Mo.... 

12  Mo. . . . 

7.5 

7.5 

8 

8.5 
10.75 
12.50 
14 
15 
16 

16.75 
17.50 
18.25 
19 
20 
21 

2 

2 

3 
4 
5 
5 

6 

6^ 

8 

8 

8 

8 
10 
10 

2 
2 
2 

i« 

3 
3 

4 

20 

20 

22  J^ 

24 

28 

35 

35 

36 

39 

40 

40 

40 

40 

40 

40 

7 
7 

8 
9 
14 
19 
21 
23 
25 
27 
28 
29 
32 
35 
40 

IS 
18 

1 
1 

1 
1 

1 
1 

1 
H 

0 

12 
12 

14 

13 

16 

13 

11 

13 

13 

12 

10 

7 

4 

0 

1.4 

1.4 

1.4 

1.5 

2 

2.2 

2.5 

2.6 

2.6 

2.6 

2.8 

2.9 

3.2 

3.5 

4 

1.4 

1.4 

1.4 

1.5 

2 

2.2 

2.5 

2.6 

2,6 

2.6 

2.8 

2.9 

3.2 

3.5 

4 

7.5 

7.5 

7 

6.5 

6 

5.2 

5.5 

5.5 

5.3 

5.1 

5.3 

5.4 

5.1 

4.75 

4 

307 
307 
318 
339 
444 
519 
560 
603 
645 
687 
708 
729 
760 
800 
840 

300 
300 
320 
340 
430 
500 
560 
600 
640 
670 
700 
730 
760 
800 
840 

juice,  should  always  precede  or  follow  the  bottle,  which  remains  the  chief 
part  of  the  meal. 

It  may  be  noted  by  a  glance  at  the  whole-milk  table  that  the  fat  per- 
centages are  somewhat  lower  and  the  protein  and  carbohydrate  percentages 
somewhat  higher  than  is  commonly  recommended  by  American  authors. 
These  changes  from  the  routine  formulas,  however,  are  not  objectionable, 
since  they  make  the  food  more  easily  digested.  The  diminished  amount  of 
fat,  which  is  rather  difficult  of  digestion  for  the  average  infant,  is  made  up 
by  the  increase  in  carbohydrates,  which  are  very  easily  digested,  and  both  of 
these  changes  facilitate  protein  digestion.  The  object  of  the  table  is  to 
offer  a  method  so  simple  that  the  busy  physician  can  hold  it  in  his  mind 
and  by  it  make  modified  milk  mixtures  which  conform  both  to  the  per- 
centage method  and  caloric  standard. 

Carbohydrate  Diluents. — The  carbohydrates  in  these  milk  formulas  may 
be  changed  at  the  will  of  the  physician,  and  in  doing  so  it  should  be  remem- 
bered that  all  carbohydrates  used  in  infant  feeding  have  practically  the 
same  food  value.  One  ounce  of  milk  sugar  has  the  same  caloric  value  as 
1  ounce  of  cane  sugar,  wheat  flour,  barley  flour,  or  oatmeal,  and  in  making 
the  carbohydrate  diluent  of  an  infant  food  they  should  all  be  used  in  the 
proportion  of  one-half  ounce  to  the  pint  of  water.  In  very  young  infants 
it  is  perhaps  better  to  use  dextrinized  gruels  made  from  barley  or  wheat. 
In  older  infants  (after  the  third  or  fourth  month)  the  unchanged  cereal 
gruels  made  from  barley,  wheat,  and  oats  answer  quite  as  well  as  those  which 
have  been  dextrinized.  The  carbohydrate  diluents  facilitate  the  digestion  of 
protein.     This  action  is  perhaps  purely  mechanical  in  that  the  casein  of 


HOME   MODIFICATION   OF   MILK  139 

milk,  when  surrounded  by  a  carljohydrate  mixture,  is  precipitated  in  finer 
floccula?  and  large  curd  formation  is  prevented. 

Alkaline  Diluents. — Experience  has  taught  that  the  addition  of  alka- 
lies to  modified  milk  mixtures  facilitates  their  digestion.  The  alkalies  in 
most  common  use  are  lime  water  and  bicarbonate  of  soda.  The  alkalies 
facilitate  the  digestion  of  casein  by  inhibiting  the  action  of  the  rennet 
ferment,  delaying  the  coagulation  of  casein  and  neutralizing  the  fermenta- 
tion acids.  Of  the  two  alkaline  diluents,  lime  water  and  bicarbonate  of 
soda,  lime  water  is  more  commonly  used.  It  has  the  same  action  as  the 
soda  in  preventing  tough  curd  formation  and  acts  more  powerfully  in 
stimulating  the  secretion  of  hydrochloric  acid.  Lime  water  should  be  used 
in  the  strength  of  1  or  2  ounces  to  every  20  ounces  of  food,  and  bicarbonate 
of  soda,  1  grain  for  every  ounce  of  food.  Chlorid  of  soda  may  be  used 
instead  of  the  bicarbonate  in  the  same  strength.  If  alkalies  are  used  in  too 
large  quantities  all  action  in  the  stomach  on  casein  is  suspended,  and  it 
passes  uncoagulated  into  the  small  intestine.  If  this  action  of  the  alkalies 
is  desired  to  prevent  the  coagulation  of  the  milk  in  the  stomach,  2  to  2^^ 
grains  of  bicarbonate  of  soda  should  be  used  for  each  ounce  of  food.  Citrate 
of  soda  is  not  an  alkali,  but  when  added  to  milk  it  decalcifies  the  casein, 
and  prevents  the  action  of  the  rennet.  This  decalcified  casein  forms  with 
hydrochloric  acid  soft,  friable  flakes,  in  this  way  preventing  the  formation 
of  tough  curds.  It  may  therefore  be  of  considerable  value  in  promoting 
the  digestion  of  milk  when  there  is  a  tendency  to  tough  curd  formation. 
One  grain  of  sodium  citrate  for  each  ounce  of  milk  in  the  food  will  insure 
the  formation  of  soft  curds  instead  of  tough  ones. 

Determination  of  Accurate  Percentages. — For  those  who  desire  to  use 
food  formulas  in  which  the  percentages  of  the  important  ingredients  are 
more  accurately  determined,  the  following  table,  adapted  by  Southworth 
from  that  of  J.  F.  Connors  is  given  on  page  140. 

Southworth  says:  "The  proteids  have  been  calculated  upon  the  basis 
of  both  4  per  cent,  and  3.50  per  cent.  The  former,  4  per  cent.,  is  for 
those  who  use  round  numbers  to  facilitate  mental  calculation  of  percent- 
ages. The  latter,  3.50  per  cent.,  which  is  the  actual  percentage  of  proteids 
in  good  average  milk  having  4  per  cent,  fat,  is  to  enable  the  practitioner 
to  determine  readily  the  more  exact  amount  of  proteids  in  any  given  mix- 
ture. Either  column  may  be  used  for  the  purpose  of  making  a  mixture  of 
any  desired  percentages  or  in  determining  the  percentages  contained  in  any 
mixture  of  known  proportions.  To  make  up  any  desired  percentage  mix- 
ture (1)  find  in  the  one  of  the  proteid  columns  determined  upon  the  de- 
sired percentage,  or  that  which  is  nearest  it;  (2)  move  in  a  horizontal  line 
to  the  right  until  the  desired  percentage  of  fat  is  reached,  or  one  which  is 
nearest  to  it;  (3)  the  heading  of  this  fat  column  tells  what  kind  of  milk 
is  to  be  used ;  (4)  on  the  same  line  with  the  fat  percentage  at  the  right 
will  be  found  the  fraction  showing  the  necessary  proportions  of  this  milk 
or  top  milk  in  the  food  mixtures  to  give  the  percentages  selected,  and  be- 
yond this  will  be  found  the  number  of  parts  of  such  milk  or  top  milk  and 


HI 


O 

W 


P 

•J 

Q 


h  2 


o« 


•B^I«d    l«'°X 


inanjia  s^J^J 


niiW  tJ^X  -"o  1HIM  ^^-"^J 


>n'-'r»®>'5'»'Wc<NM'-ic<5'H.-ii-i 


HMi-llO(NC0^ 


jjljj^  JO  enoi^iodojj 


-E-E:^-*-:>*'*.i:^«-::?;'*^:^^:5^'' 


dox     ■><>   aioiM    'paoiHiiJis  ioj 


oooooi-<'-ii-irte^e<coc<5coT»i 


saniix  ^  '  %9I  »«>i  "^'O  i  ^^^x 


3II!W  ajoqM 
saniiX  8   '%ZI  »*^  "^^O  6  d^x 


8aniix5<Z'%0I  ?«i  "B«0  II  dox 


samiX  Z  '%8  »»J  "s'O  ST  dox 


samix  Hi  *%9  *«>i  "8*0  OS  'dox 


Oe<90cotoe»o«oc<5-<>'OOOOoo 
f-<i-<cie>iNeO'«''*>nebooooN(N 


t»t>.U5P'»"OOOtOOO>flP500 

■  mcOOOOOOt^MiON 


Oi-i.-i(NN(Nro'J<'>J«iflt>.0CC>O'- 


lOoo-Hoooinooooooo 


OO'-'-^'-HMINlNWTl'iOOtOt^CC 


50'- 


coooot^ooorooo 


00'<-Hrti-<MCie^W>>'U3»OtDO 


r>.Q>0OpOOOpOQU3QOO 

Oddd'-H»Ht-lr-.CJ(NC<5P3T»lll<T»I 


%f  inoqv  »«J  'inw  aioiAl  PooQ 


%I  »noqv  *«J  'mn  pannnpig 


iocoor^r^top'»«<«opp^.po 
ddddddi-ii-ii-(^Ne<iNcow 


ooooooooooooooo 


OS 


(fa. 


piatojj  %oeg  '3inw  dox 
JO  'aioq^  'patmnpig  uj  'aaB 
-iirao  ja J  jBniav  amMoqg  sajnSi j 


C<»'*OOOOpOO"50C>5MQ 

ddddddd-<'--Hrtejcioie« 


pia^ojj  %^  '5jni\:  dox  JO 
'a|oq^  'paintnpis  uj  •snoi'jB| 
-n3j«5  [wjoaj^i  li;  pasjl  Bajn8j j 

140 


dddddd'-'-<i-<-<NeiN«eo 


KOIVH    LAROHATOHY    MKTllOh    OV    MODlKVlNd    MII.K       111 

of  diluent  which  must  bo  usod  ;  (A)  dip  olT  llit»  pro|u'r  milk  mid  dihilo  all 
or  a  part  of  it.  dopondin^  ou  lh<'  (piaiditv  of  (lu«  ftrnd  lo  l)t>  made  up;  ((i) 
the  addition  of  \?V2  f^irlv  Imol  tal)U's|)tuM»ruls  (»f  milk-HUpir  or  '.'  i>\aotly 
levol  tablospiHinfuls  of  jinuudntod  sujK'ar  for  about  uvery  I^OOhikcs  of  the 
total  luixtmv  will  givo  tho  })ropor  |H>riH'Mta^t's  of  Hugnr." 

THE  ROTCH  LABORATORY  METHOD  OF  MODIFYINO  MILK 

Tho  world  owes  to  T.  M.  Roteh,  of  Boston,  a  histinpf  debt  of  gratitude 
for  the  work  he  has  done  in  ontlininj:;.  eslablishin^',  and  p(i|)Ml;ii  i  in"  [n  r 
centage  feeding.     In  aeeonipiishinj;  Ibis  work  be  lias  used  as  lir  .i;miiI;;  (1h« 
Walker-Gordon  Milk  Laboratories,     'rbcsc  laboratoricH  have  tho  following 
stock  supplies: 

1.  A  3i'-])er-cent.  fat  cream  mixture. 

2.  Separated  milk  which  is  almost  fat-froo. 

3.  A  20-per-cent.  solution  of  milk  sugar.  Other  sugars  such  as  mal- 
tose, sucrose,  and  dextrose  may  be  j)re8cribod. 

4.  Whey. 

5.  Cereal  decoctions. 

6.  Lime  water  and  other  alkalies  used  in  modifying  milk. 

From  these  supj)lie8  the  physician  may  prescribe  a  milk  mixture  calling 
for  specified  percentages  of  fat,  protein,  carbohydrates,  and  alkalies,  desig- 
nate the  amount  in  ounces  for  each  feeding  and  tlie  niimber  of  feedings  in 
twenty-four  hours.  The  whole  supply  to  be  delivenid  each  morning  in  a 
neat,  clean  box  with  compartments  for  holding  the  individual  bottles  and 
each  bottle  containing  the  amount  of  the  mixture  prescribed  for  a  single 
nursing.  The  nurse  or  mother  has  only  to  warm  the  milk  mixture*  by 
placing  the  bottle  in  warm  water  and  then,  on  taking  out  the  cotton  stop- 
per and  slipping  a  nipple  over  the  mouth  of  the  bottle,  it  is  ready  for  tho 
baby  to  take. 

The  milk  laboratories  under  the  Walker-Gordon  management  are  as  re- 
liable as  milk  laboratories  can  be  made.  The  stock  maUtrhih  from  which 
the  modified  milk  is  compounded  are  as  clean  and  wholesome  as  s(;i(!ntiflc 
methods  can  make  them.  And  the  compounding  is  done  with  such  accuracy 
that  the  physician  may  rely  upon  getting  the  percentages  of  the  various 
ingredients  as  he  has  ordered  them. 

The  following  is  a  typical  laboratory  prescription : 

Per  Cent.  Remark* 


J^     Fats    3.00 

Milk  sugar   6.00 

Protein  total    1.00 

"         (whey)   0.75 

**         (casein)   0.25 


Nnmber  of  feoAVmnn 9 

Amount  at  each  teoAing.  .  .Z  ounce* 

Infant  'n  age «...  1  month 

Infant  'n  wei(;ht 9  pounds 

Alkalinity,  lime  water ft  per  cent. 

Heat  at 150°  P 


If  the  original  formula  prescribed  for  the  baby  does  not  agree  with  it, 
or  does  not  meet  its  nutritional  demands,  any  (me  or  all  of  the  vari^rtw 


142  ARTIFICIAL   FEEDING 

ingredients  may  be  changed  at  the  will  of  the  physician  by  simply  writing 
a  new  prescription.  The  laboratory  method  of  percentage  feeding  is  the 
simplest  and  most  accurate.  The  expense,  however,  of  thirty  to  forty  cents 
a  day  which  it  entails,  and  the  location  of  these  laboratories  in  only  a  few 
of  our  largest  cities  shut  out  the  vast  majority  of  infants  from  the  advan- 
tages which  this  method  offers. 

ADDITION  TO  DIET  OF  BOTTLE-FED  INFANTS 
AND  CHILDREN 

Foods  Added  in  the  First  Twelve  Months  of  Infancy. — The  exact  time 
at  which  other  food  shall  be  added  to  the  diet  of  the  bottle-fed  infant  de- 
pends altogether  upon  the  digestive  capacity  of  the  individual,  and  what  is 
here  said  applies  to  the  average  normal  infant.  Of  course  delicate  infants 
of  the  same  age  will  have  to  be  placed  upon  a  diet  suitable  to  an  infant 
several  months  younger;  and  strong,  sturdy  infants  of  unusual  physical 
development  may  be  able  to  take  food  which  in  the  average  is  suitable  for 
children  several  months  older. 

Orange  juice  is  one  of  the  most  valuable  of  infant  foods  and  is  almost 
indispensable  when  the  infant  is  fed  upon  sterilized  foods.  Under  these 
conditions  it  prevents  scurvy  and  overcomes  constipation.  It  may  be  added 
to  the  diet  at  the  eighth  month.  The  juice  of  half  an  orange  is  to  be  given 
daily  between  feedings.  At  the  end  of  the  first  year  the  quantity  may  be 
increased  to  a  whole  orange. 

Meat  juice  is  also  a  valuable  food  which  may  be  begun  as  early  as  the 
eighth  or  ninth  month,  one  ounce  twice  a  day  with  a  bottle  feeding.  Both 
the  orange  and  the  meat  juice  remain  as  staple  articles  of  the  infant's  and 
child's  diet  for  two  or  three  years. 

Foods  Added  to  the  Diet  from  the  Twelfth  to  the  Eighteenth  Month. 
— Cereals,  covered  with  clean  milk  and  sugar  or  salt,  may  be  begun  at  the 
end  of  the  first  year.  A  tablespoonful  of  well-cooked  cereal,  followed  by 
six  ounces  of  milk,  making  one  of  the  meals.  The  following  cereals  are 
recommended :  Oatmeal,  cream  of  wheat,  wheatena,  and  rice.  In  the  be- 
ginning not  more  than  one  cereal  feeding  should  be  given  in  a  day.  Broths 
made  from  beef,  lamb,  or  chicken  and  slightly  thickened  with  one  of  the 
cereals  may  next  be  added  to  the  diet ;  not  more  than  six  ounces  of  broth 
should  be  given  and  this  should  be  followed  by  a  six-ounce  bottle,  making 
a  meal.  Fresh,  soft-boiled  eggs  are  perhaps  the  most  valuable  addition  to 
the  infant's  diet  at  this  time.  They  are  easily  digested  and  in  the  begin- 
ning it  may  be  wise  to  alternate  with  the  cereals,  giving  an  egg  every  second 
or  every  third  day.  The  white  of  the  egg  mixed  with  eight  ounces  of  water 
is  a  food  that  may  be  used  even  during  the  first  year  of  life.  Bread,  toast, 
rusk,  and  crackers,  softened  with  milk,  may  be  given  as  a  part  of  one  of 
the  meals  at  this  time. 

The  normal  infant  from  fifteen  to  eighteen  nionths  of  age  should  have 
five  feedings  daily,  and  four  of  these  feedings  should  be  supplemented  as 


ADDITION   TO   DIET  143 

follows:  A  cereal  with  the  first  meal,  broth  with  the  second,  egg  with  the 
third,  bread  or  toast  with  the  fourth,  and  following  each  of  these  a  six- 
ounce  bottle  of  whole  milk.  The  orange  juice  still  remains  a  part  of  the 
diet. 

Foods  Added  from  the  Eighteenth  to  the  Twenty-fourth  Month. — Prune 
juice  or  apple  sauce  may  be  added  to  the  six-o'clock  meal  at  this  time. 
Potato,  baked,  or  boiled  and  mashed,  may  now  alternate  with  the  cereals. 
Beef  balls  made  by  broiling  scraped  beef  may  alternate  with  the  egg  and 
later  take  the  place  of  the  broth.  During  this  period  the  ten-o'clock  feed- 
ing is  discontinued  and  the  child  has  but  four  feedings  a  day. 

Foods  Added  during  the  Third  Year. — Fresh  vegetables  such  as  aspar- 
agus tips,  peas,  string  beans,  stewed  celery,  and  spinach  are  now  a  part  of 
the  child's  diet.  One  of  these  may  be  given  each  day.  Desserts  such  as 
rice  pudding,  bread  pudding,  baked  custard,  junket,  and  ice  cream  made 
from  clean  milk  may  be  gradually  added  to  the  child's  diet;  ice  cream, 
however,  should  not  be  given  more  than  once  or  twice  a  week  and  then 
only  toward  the  end  of  the  third  year.  Eaw  fruits,  such  as  peaches,  apples, 
pears,  and  grapes,  may  now  occasionally  take  the  place  of  apple  sauce  or 
orange  juice.  Meats,  such  as  lamb  chops,  chicken,  fish,  or  beef,  may  be 
minced  and  moistened  with  beef  juice  or  broth  and  given  once  a  day. 
Breads  of  various  kinds,  such  as  corn  bread  and  dry  cold  biscuits,  are  now 
wholesome  articles  of  food.  By  the  end  of  the  third  year  the  child  should 
have  but  three  meals  a  day. 

From  the  Fourth  to  the  Sixth  Year. — From  the  fourth  to  the  sixth 
year  the  following  foods  should  be  excluded  from  the  child's  diet.  Tea, 
coffee  and  alcoholic  drinks,  pastry,  nuts  and  sweets,  except  very  simple 
cakes  and  an  occasional  piece  of  good  candy,  pork,  preserved  meats,  raw 
vegetables,  salads,  griddle  cakes,  and  fried  food  of  all  kinds. 

From  the  above  diet  list  it  will  be  easy  to  prescribe  a  diet  suitable  to  the 
age  of  the  child.  But  throughout  all  of  this  time  it  is  most  important  that 
milk  should  remain  the  basis  of  the  child's  diet  and  care  should  be  taken 
that  it  should  not  be  overfed.  There  is  little  or  no  danger  in  underfeeding 
the  normal  child. 


11 


SECTION   IV 

DISEASES  OF  DIGESTIVE  SYSTEM 

CHAPTER  XV 
DENTITION 

THE  TEMPORARY  TEETH 

Eruption  of  the  Temporary  Teeth. — The  mouth  of  the  infant  for  the 
first  six  or  eight  months  of  life  contains  no  teeth.  The  absence  of  teeth  at 
this  time  serves  a  wise  purpose  in  that  the  infant  can  better  perform  the 
act  of  sucking.  The  formation  of  the  temporary  teeth  begins  in  early  fetal 
life  and  continues  until  at  birth  they  are  inclosed  in  membranous  tooth 
sacs,  more  or  less  deeply  imbedded  in  the  alveolar  processes  of  the  jaws, 
covered  only  by  the  submucous  connective  tissue  and  the  mucous  membrane. 
The  temporary  teeth  are  twenty  in  number,  and  at  birth  the  dental  sacs 
which  hold  them  rest  upon  the  sacs  of  the  permanent  teeth.  The  eru])tion 
of  the  temporary  teeth  through  the  gums  begins  between  the  sixth  and  the 
eighth  month  and  is  usually  not  completed  until  in  the  early  months  of 
the  third  year  of  life.  These  teeth  usually  make  their  appearance  in  crops 
or  groups  of  two  or  four,  followed  by  a  six  or  eight  weeks'  interval  of  rest. 
The  eruption  of  the  temporary  teeth,  on  the  whole,  follows  a  definite  order 
which  may  vary  even  in  well  infants,  but  these  variations  are  greatly  exag- 
gerated in  rachitic,  syphilitic,  and  otherwise  malnourished  infants.  On  the 
whole,  the  teeth  come  through  earlier  and  conform  more  closely  to  the 
regular  order  of  eruption  in  the  breast-fed  than  in  the  artificially  nourished 
infant.  The  following  table  shows  the  usual  order  and  the  average  time 
of  eruption  of  the  different  groups  of  teeth.  These  variations  are  within 
normal  physiological  limits: 

Two  lower  central  incisors 6  to  8  months 

Two  upper  central  incisors 8  to  12  months 

Two  upper  lateral  incisors 9  to  12  months 

Two  lower  lateral  incisors 12  to  15  months 

Four  anterior  molars 13  to  16  months 

Tour  canines 18  to  22  months 

Pour  posterior  molars 22  to  30  months 

When  one  year  of  age  an  infant  should  have  six  teeth;  when  one  and 
one-half  years  of  age,  ten  or  twelve  teeth;  when  two  years  of  age,  sixteen 

144 


THE   TEMPORARY   TEETH  145 

teeth ;  when  two  and  one-half  years  of  age,  twenty  teeth.  In  rare  instances 
infants  may  be  born  with  teeth;  when  this  occurs  it  is  almost  always  the 
lower  central  incisors  that  are  present.  This  congenital  anomaly  is  of 
little  pathological  importance.  In  many  instances  these  teeth  are  set  so 
loosely  in  the  gums  that  they  act  as  an  irritant  and  interfere  with  nursing ; 
when  this  is  the  case  they  should  be  removed.  When,  however,  they  are 
firmly  set  in  their  alveolar  processes  they  should  be  let  alone ;  their  presence 
causes  neither  the  infant  nor  the  mother  any  inconvenience  and  their  re- 
moval deprives  the  infant  of  just  so  many  temporary  teeth. 

Delayed  Dentition. — Rickets  and  other  forms  of  malnutrition  are  the 
common  causes  of  delayed  dentition,  but  heredity  may  also  be  a  factor.  If 
no  teeth  have  appeared  by  the  end  of  the  first  year  of  life,  rickets  should 
be  suspected  and  other  symptoms  of  this  disease  sought  for.  The  same 
causes  which  delay  dentition  predispose  to  irregularities  in  the  time  of 
eruption  of  the  various  groups ;  for  example,  the  upper  incisors  may  appear 
before  the  lower  and  the  canines  before  the  molars.  In  malnourished  chil- 
dren the  teeth  not  only  come  in  late  and  irregularly,  but  they  are  poorly 
developed,  imperfectly  formed,  and  decay  early. 

Dentition  as  a  Pathological  Factor. — At  one  time  in  the  history  of 
medicine  almost  all  the  ills  of  infancy  and  early  childhood  which  occurred 
during  teething  were  attributed  in  a  greater  or  less  degree  to  dentition. 
At  that  time  it  was  believed  to  be  the  all-important  cause  of  gastrointestinal 
disturbances  and  of  functional  nervous  disorders.  Diarrhea,  enteritis,  sleep- 
lessness, general  nervous  irritability,  convulsions,  running  ears,  and  even 
diseases  of  the  respiratory  passages  were  attributed  to  dentition.  In  recent 
years,  as  the  causes  of  diarrheal,  nervous,  and  other  diseases  in  infancy  have 
been  more  carefully  worked  out,  dentition  has  gradually  lost  its  importance 
as  a  pathological  factor.  The  teachings  of  Forchheimer  played  no  little 
part  in  this  reaction.  He  strongly  maintained  that  dentition  rarely  played 
any  role  either  in  producing  or  aggravating  pathological  processes,  and 
taught  that  "teething  produces  teeth  and  nothing  more."  While  Forch- 
heimer recognized  that  certain  slight  and  evanescent  symptoms  might  be 
due  to  teething,  he  held  that  the  safety  and  welfare  of  the  infant,  during 
this  period,  largely  depended  upon  the  clinician  disregarding  dentition  as 
a  pathological  factor  and  searching  for  other  remedial  causes  of  the  in- 
fant's illness.  However,  it  is  important  that  we  should  not  altogether  for- 
get that  teething  is  not  infrequently  accompanied  by  pain  and  by  certain 
symptoms  on  the  part  of  the  nervous  system  and  gastrointestinal  tract.  In 
a  perfectly  normal  breast-fed  infant  a  tooth  may  come  through  without 
producing  any  symptoms  whatever;  the  first  evidence  of  its  eruption  may 
be  the  finding  of  its  tiny  point,  which  has  pierced  the  gum  over-night,  but 
this  is  not  usually  the  case  even  in  normal  infants.  The  most  common 
symptoms  due  to  teething  are  swelling,  redness  and  tenderness  of  the  gums, 
increased  flow  of  saliva,  sleeplessness,  marked  restlessness,  increased  nerv- 
ous irritability,  exaggerated  reflex  excitability,  elevation  of  temperature, 
refusal  to  take  food,  regurgitation  of  food,  vomiting,  intestinal  indigestion. 


146  STOMATITIS 

and  slight  looseness  of  the  bowels.  In  rachitic  and  malnourished  infants 
these  symptoms  are  so  much  more  marked  that  one  might  almost  say  that 
their  severity  is  largely  dependent  upon  the  degree  of  malnutrition  from 
which  the  infant  is  suffering. 

Care  of  the  Teeth.— It  is  rarely  if  ever  necessary  to  lance  the  gum  to' 
relieve  the  symptoms  which  are  believed  to  be  associated  with  diflficult  den- 
tition. The  majority  of  pediatricians  never  find  it  necessary  to  make  this 
operation.  It  is  important  to  take  proper  care  of  the  temporary  teeth,  since 
they  serve  the  purpose  of  preserving  the  shape  of  the  jaw  and  making 
second  dentition  more  normal  and  less  difficult;  they  are  to  be  kept  clean 
by  washing  the  mouth  once  or  twice  a  day  with  lukewarm  water,  or  with 
a  weak  boracic  solution.  Particles  of  food  materials  must  not  be  allowed 
to  collect  between  the  teeth  or  at  their  roots,  and  thus  furnish  a  culture 
field  for  pathogenic  microorganisms. 

THE  PERMANENT  TEETH 

Permanent  teeth  are  thirty-two  in  number.  The  first  molars,  which 
appear  earliest,  penetrate  the  gum  about  the  sixth  or  seventh  year.  Forch- 
heimer's  table,  which  follows,  gives  the  time  of  the  appearance  of  the  sec- 
ond set  of  teeth. 

First  molars 6  years 

Incisors 7  to     8  years 

Bicuspids   9  to  10  years 

Canines 12  to  14  years 

Second  molars 12  to  15  years 

Third  molars 17  to  25  years 

Malnutrition  of  a  pronounced  type  may  delay  and  interfere  with  second 
dentition  just  as  it  does  with  first  dentition.  In  congenital  syphilis  the 
second  teeth  are  poorly  formed,  decay  early  and  in  some  instances  the  upper 
central  incisors  show  a  characteristic  deformity  known  as  Hutchinson's 
teeth.  This  condition  is  described  under  Congenital  Syphilis.  In  neurotic 
malnourished  children  the  eruption  of  the  second  teeth  may  act  as  a  reflex 
factor  in  the  production  of  nervous  symptoms  and  digestive  disturbances 
somewhat  less  severe  than  the  symptom  group  produced  by  the  first  den- 
tition. 

CHAPTER    XVI 
STOMATITIS 

STOMATITIS  CATARRHALIS 

Symptomatology. — Stomatitis  catarrhalis  is  a  simple  inflammation  of 
the  mucous  membrane  of  the  mouth.  It  usually  begins  on  the  gums  or 
tongue  and  spreads  to  involve  the  entire  mucous  membrane  of  the  mouth. 
It  is  characterized  by  redness  and  swelling  of  this  membrane,  and  by  an 


STOMATITIS  APHTHOSA  147 

increasing  salivary  and  mucous  secretion.  Wlien  the  disease  is  well  estab- 
lished the  mucous  membrane  is  intensely  congested  and  slight  hemorrhages 
may  occur.  The  gums  are  usually  much  swollen,  and  this  may  extend  to 
tlie  lips,  causing  a  decided  thickening.  The  pain  and  irritation  cause  the 
infant  to  be  fretful,  sleepless,  and  to  refuse  food.  The  act  of  sucking  ap- 
parently causes  pain.  The  salivary  glands  are  excited  to  increased  activity, 
so  that  the  saliva  flows  out  of  the  mouth,  wetting  the  face  and  clotliing. 
Forchheimer  calls  attention  to  the  enlargement  of  the  muciparous  follicles 
which  appear  as  small,  round  prominences  on  the  red  mucous  membrane, 
and  to  the  fact  that  in  older  infants  the  swollen  tongue  and  cheeks  show 
the  indentations  of  the  teeth.  The  temperature  is  normal  or  slightly  ele- 
vated. The  lymph  nodes  are  not  enlarged.  The  infant's  general  nutrition 
may  suffer  slightly  because  of  the  lack  of  food  and  general  nervous  irrita- 
bility. When  constitutional  symptoms  are  marked  the  catarrhal  stomatitis 
is  then  a  symptom  of  some  acute  toxic  condition. 

Etiology. — This  condition  is  most  common  during  the  first  year  of  life. 
It  is  produced  by  some  mechanical,  chemical,  toxic  or  thermal  injury  to  the 
mucous  membrane  (Forchheimer).  The  introduction  of  foreign  bodies, 
carelessness  or  roughness  in  washing  the  mouth,  strong  acids  or  alkalies, 
dirt,  decomposing  food,  pacifiers,  and  hot  and  cold  food  are  among  the  com- 
mon exciting  causes.  Catarrhal  stomatitis  is  usually  present  in  most  of  the 
acute  infectious  diseases. 

Treatment.^The  disease  runs  a  benign  course  and  terminates  in  recov- 
ery within  five  or  six  days,  provided  the  mouth  is  kept  clean  and  the  excit- 
ing cause  is  removed.  The  mouth  may  be  washed  with  a  2  or  3  per 
cent,  solution  of  boracic  acid  or  with  a  mild  alkaline  antiseptic.  A  laxative 
should  be  given,  preferably  castor  oil,  and  the  milk,  if  the  infant  be  arti- 
ficially fed,  should  be  diluted  with  barley  water;  cool  food  is  more  readily 
taken.  It  is,  as  a  rule,  bad  practice  to  attempt  to  force  food  in  these  cases; 
in  some  instances,  however,  the  modified  milk  mixture  will  be  taken  readily 
with  a  spoon  even  after  the  infant  has  refused  to  nurse.  Weak  solutions  of 
some  astringent,  such  as  a  one-half  per  cent,  solution  of  nitrate  of  silver,  is 
recommended  in  those  cases  where  for  any  reason  the  disease  is  prolonged 
beyond  a  week. 

STOMATITIS  APHTHOSA 

Etiology. — The  causes  of  this  condition  are  not  definitely  known.  It 
has  been  suggested  that  it  is  brought  about  by  intestinal  or  other  toxins; 
that  it  is  of  neurotic  origin;  that  it  is  a  local  infection  due  to  pathogenic 
microorganisms  and  associated  with  uncleanliness  and  fermenting  food 
material  in  the  mouth.  It  is  sometimes  associated  with  the  acute  infectious 
diseases  and  with  severe  disturbances  of  the  gastrointestinal  canal. 

Symptomatology. — This  condition  has  been  described  under  the  name 
herpetic  stomatitis,  maculofibrinous  stomatitis,  vesicular  stomatitis  and  fol- 
licular stomatitis.  It  is  characterized  by  the  appearance  of  superficial 
ulcers,  scattered  widely  over  the  soft  palate,  hard  palate,  gums,  tongue,  and 


148  STOMATITIS 

the  inner  surface  of  the  lips  and  cheek.  These  ulcers  appear  as  yellowish- 
white  spots,  covered  with  a  fibroplastic  exudate  and  surrounded  by  an  area 
of  congested,  swollen  and  reddened  mucous  membrane.  There  may  be 
only  a  few  of  these  ulcers  present,  or  the  whole  mucous  membrane  of  the 
mouth  may  be  dotted  with  them.  These  small,  round,  yellowish-white 
ulcers,  from  one-eighth  to  one-fourth  of  an  inch  in  diameter,  present  a  very 
characteristic  appearance.  If  near  together  they  may  coalesce  to  form 
larger,  irregular  ulcers.  The  catarrhal  stomatitis,  which  is  always  asso- 
ciated with  this  condition,  is  more  intense  in  the  immediate  vicinity  of  the 
ulcers.  There  is  great  increase  in  the  salivary  flow,  and  drooling  is  always 
present.  The  pain  is  very  intense  and  is  greatly  aggravated  by  any  irri- 
tating material  coming  in  contact  with  the  ulcers.  For  this  reason  infants 
suffering  from  this  condition  may  abstain  almost  absolutely  from  food  for 
two  or  three  days  at  a  time,  and  a  paroxysm  of  crying  and  nervous  irrita- 
bility may  be  provoked  by  any  attempt  at  feeding.  This  condition  occurs 
most  commonly  during  the  second  year  of  life,  so  that  children  suffering 
from  it  can  usually  be  induced  to  take  water  or  some  non-irritating  food 
such  as  milk  or  barley  water  from  a  spoon  when  they  absolutely  refuse  to 
take  it  from  a  nursing  bottle.  Not  infrequently  gastrointestinal  disturb- 
ances are  associated  with  this  form  of  stomatitis. 

Prognosis. — This  disease  runs  a  benign  course  and  terminates  in  re- 
covery within  a  week  or  ten  days. 

Treatment. — This  should  be  begun  with  a  dose  of  castor  oil,  to  be  fol- 
lowed by  a  very  bland  diet.  Irritating  food,  such  as  broths  and  meat  juice 
which  contain  salt,  cause  pain  and  are  refused.  Cool  water  and  cow's  milk 
diluted  with  barley  water  should  be  given  to  the  child  to  drink  or  should 
be  fed  with  a  spoon.  The  mouth  should  be  washed  with  mild  alkaline  non- 
irritating  antiseptics;  a  weak  solution  of  boracic  acid  may  be  used  for  this 
purpose. 

STOMATITIS  MYCOSA 

{Sprue;  Thrush) 

Etiology. — Thrush  is  produced  by  a  specific  fungus  which,  under  the 
microscope,  presents  the  appearance  of  fine,  tangled,  jointed  filaments. 
These  slender  threads  are  composed  of  rods  with  spores  at  their  ends,  and 
scattered  through  the  tangled  threads  isolated  spores  and  epithelial  cells 
are  seen.  These  fungi,  as  Forchheimer  has  taught,  penetrate  beneath  the 
epithelial  layers,  lifting  and  separating  them;  in  this  way  the  disease 
spreads  along  the  surface  and  into  the  deeper  layers  of  the  mucous  mem- 
brane and  in  rare  instances  invades  the  underlying  tissues  and  distant 
organs.  It  most  commonly  attacks  the  mucous  membrane  of  the  cheeks, 
hard  palate  and  tongue;  other  portions  of  the  mouth  are  not  uncommonly 
involved,  and  much  more  rarely  the  pharynx,  stomach  and  intestines  are 
attacked  by  this  fungus.  It  occurs  most  commonly  during  the  first  three 
months  of  life  among  infants  whose  surroundings  are  dirty  and  unhygienic 


STOMATITIS   MYCOSA 


149 


and  who  are  improperly  fed  and  neglected.  Catarrhal  stomatitis  usually 
precedes  thrush  and  prepares  the  mucous  membrane  for  inoculation  with 
the  fungus  of  this  disease.  All  the  exciting  factors  of  catarrhal  stomatitis 
become,  therefore,  the  predisposing  factors  of  thrush.  This  disease  is  very 
much  more  common  in  malnourished,  marasmic  infants  and  is  therefore 
more  prevalent  in  hospital  and  dispensary  practice.  The  contagion  is  very 
widespread;  it  may  be  found  on  the  buccal  mucous  membranes  of  healthy 
infants.  This  impresses  the  fact  that  susceptibility  to  this  disease  is  an 
important  etiological  factor.  Normal  mucous  membranes  are  capable  of 
resisting  it,  but  diseased  and  injured  mucous  membranes  furnish  a  favor- 
able soil  for  its  growth.  General  lack  of  resistance,  associated  with  profound 
malnutrition,  is  also  an  important  factor,  not  only  in  starting  the  growth, 
but  in  facilitating  its  spread. 

Symptomatology. — This  disease  is  readily  recognized  by  the  appearance 
on  the  tongue,  cheeks  or  other  portions  of  the  mouth  of  small,  white 
patches  which  resemble  coagulated  milk.  These  white  masses  seem  to  be 
loosely  attached,  but  on  attempting  to  remove  them  they  are  found  to  cling 
closely  and  to  be  imbedded  in  the  mucous  membrane;  their  removal  leaves 
raw  and  bleeding  surfaces;  by  this  fact  they  are  easily  differentiated  from 
milk  curds.  As  they  increase  in  size  they  coalesce  and  form  larger  irregular 
patches,  and  in  aggravated  cases  may  cover  a  large  portion  of  the  buccal 
mucous  membrane.  A  slight  catarrhal  stomatitis  is  usually  present.  The 
secretions  of  the  mouth  take  on  an  acid  reaction  due  to  the  fermentation 
produced  by  this  fungus.  There  may  be  more  or  less  difficulty  in  swallow- 
ing and  pain  on  taking  food,  which  causes  the  infant  to  refuse  nourishment. 
This  may  become  a  serious  fea- 
ture of  the  disease  when  it  occurs  #(©  _/f??5j^  _  t^^^HM 
as  a  complication  of  severe  mal- 
nutrition, and  may  in  the  maras- 
mic infant  hasten  or  cause  a  fatal 
termination.  Uncomplicated 
thrush,  however,  is  not  a  serious 
disease;  it  runs  its  course  and 
terminates  in  recovery  within  a 
week.  When  associated  with  se- 
vere constitutional  disorders, 
however,  the  disease  may  persist 
an  indefinite  length  of  time,  and 
recurrences  in  these  cases  are  not 
uncommon.      In    rare    instances 

tonsillar     or     pharyngeal     thrush  «•  myceUum;  b    spores;  c  epithelial  cells  from  the 

^  11        T   1         mouth;  o,  leukocytes;  e,  detritus.     (V.  Jaksch.) 

may    somewhat    resemble    diph- 
theria, but  the  age  of  the  infant,  the  absence  of  constitutional  symptoms, 
and,  finally,  a  microscopical  examination  which  reveals  the  thrush  fungus 
will  readily  make  the  differential  diagnosis. 

Treatment. — The  prophylactic  treatment  of  thrush  has  greatly  dimin- 


FiG.  22. — Thrush  Fungus  (Highly  Magnified). 


150  sto:matitis 

isbed  its  prevalence  in  recent  years.  If  the  infant  is  properly  cared  for 
asd  is  gi«n  clean  food  through  clean  nipples  and  is  protected  in  other 
vsn  froB  the  introduction  of  filth  and  dirt  into  its  month,  thrash  will 
rarelv  occur.  The  tendency  at  the  present  time  is  to  overdo  in  the  matter 
of  miwth-washing  in  the  healthy  infant.  Whatever  moiith--wa5hing  is  done 
imnmg  Hie  firat  few  months  of  life  shonld  not  only  be  done  with  sterile 
^f^ijify  g^  aoft  sterile  cloths,  btrt  it  should  be  done  gently  so  as  not  to 
iajne  tfie  baeeal  mucous  membrane.  Pacifiers,  dirt}-  toys  and  other  un- 
clean things  should  be  kept  out  of  the  infant's  mouth,  and  above  aU  it  should 
be  fed  carefully  alMig  the  lines  outlined  under  Infant  Feeding. 

In  the  treatment  of  thrush  a  dose  of  castor  oil  should  be  given,  and 
thereafter  the  diild  should  be  carefully  fed  as  above  indicated.  Gastro- 
intestinal disorders  and  the  underlying  malnutrition,  if  such  exist,  shoidd 
be  given  appropriate  treatment  If  the  infant  is  breast-fed,  the  mother's 
nipple,  before  and  after  nursing,  should  be  carefully  cleaiMed.  If  it  refuses 
food  it  may  sometimes  be  necessary  to  use  gavage ;  in  moet  instances,  how- 
ercr,  the  infant  may  be  fed  with  a  spoon  or  with  a  medicine  dropper. 

The  local  treatment  of  this  condition  is  simple.  The  patches  should 
be  gently  brushed  or  wiped  with  cotton  or  a  soft  cloth  saturated  with  a  mild 
alkaline  antiseptic;  a  2  per  cent,  solution  of  boric  acid  and  bicarbonate  of 
soda  serves  this  purpose  welL  In  order  to  remove  the  patches  quickly  this 
brushing  should  be  done  three  or  four  times  a  day;  care  should  be  taken, 
however,  not  to  injure  the  mucous  membrane  by  forcibly  tearing  the  patch 
away.  Stronger  applications,  such  as  a  1  per  cent,  nitrate  of  silver  solu- 
tiwL  may  be  gently  applied  once  a  day  in  those  cases  where  the  thrush 
does  not  yield  readily  to  the  boric  acid  treatm«it.  Following  the  use  of 
boric  acid  or  nitrate  of  silver  the  mouth  should  be  washed  with  sterile  water. 

STOBIATmS  X7LCEB0SA 

Etiology. — The  specific  cause  of  this  disease  is  not  definitely  known,  but 
the  dietinct  clinical  picture  which  it  presents  indicates  that  it  is  due  to 
aoBK  qjecific  microorganism.  Bemheim  and  Pospischill,  in  a  series  of 
taau,  isolated  a  bacillus  probably  identical  witii  that  of  Vincent,  which  was 
always  associated  with  a  spirochete,  and  they  apparently  demonstrated  that 
ulcerative  stomatitis  could  be  produc-ed  by  these  microorganisms.  The  fact, 
however,  that  these  microorganisms  are  also  associated  with  mercurial  sto- 
matitis, with  various  forms  of  gangrene  and  suppurative  diseases  about  the 
mouth,  together  with  the  fact  that  in  ulcerative  stomatitis,  streptococci, 
staphylococci,  and  other  pus  formers  play  an  important  role  in  the  de- 
rfmctive  proceffi,  indicates  that  the  etiological  relationship  of  the  Vincent 
badlluB  to  stomatitis  ulcerosa  has  not  been  definitely  proven.  This  disease 
oeema  mmt  commonly  in  malnourished  children  having  decayed  or  dis- 
OMcd  tedh,  which  irritate  and  mutilate  the  gums  and  furnish  a  nest  for 
decomposng  food  materiaL  Improper  food,  uncleanliness  of  the  food 
uteneile  and  everything  that  facilitates  the  carrying  of  dirt  and  micro- 


STOMATITIS    ULCEROSA  151 

organisms  into  the  child's  mouth  may  be  etiological  factors.  This  disease 
is  much  more  common  in  hospital  and  dispensary  practice. 

Ulcerative  stomatitis  also  occurs  as  a  symptom  of  scurvy  and  of  mer- 
curial and  other  metallic  poisonings. 

Symptomatology. — The  offensive  breath  and  profuse  salivation  are  the 
symptoms  which  commonly  call  attention  to  this  disease,  and  an  examina- 
tion of  the  mouth  reveals  in  the  early  stage  an  intense  redness  and  swelling 
of  the  gums,  usually  along  the  incisor  teeth.  The  swelling  and  redness 
become  more  marked,  the  gum  separates  slightly  from  the  tooth  and  a 
yellowish  ulcer  appears  on  its  edge.  As  the  disease  progresses  the  ulcera- 
tion spreads  and  extends  to  the  buccal  muc-ous  membrane  which  is  opposed 
to  the  ulcer.  The  extent  of  the  ulceration  on  the  two  opposed  mucous 
membranes  corresponds  very  closely.  As  the  ulceration  proceeds  the  gum 
becomes  more  and  more  separated  from  the  teeth,  which  may  be  loosened 
and  sometimes  may  be  lost.  The  ulcerated  mucous  membrane  is  very  tender, 
bleeds  on  the  slightest  touch,  and  causes  great  discomfort,  especially  when 
food  is  taken.  The  offensive  breath  becomes  more  fetid,  the  saliva  pours 
from  the  mouth,  and  the  large  ulcer,  which  has  resulted  in  considerable  loss 
of  tissue,  both  on  the  gum  and  the  opposed  mucous  membrane  of  the  lips 
or  cheeks,  is  covered  with  a  yellowish,  purulent  exudate.  In  rare  instances 
the  alveolar  processes  may  be  involved  and  necrosis  of  bone  may  occur. 
The  anterior  cervical  lymphatic  glands  are  swollen  and  tender.  The  tongue 
is  covered  with  a  thick,  brownish  coat.  There  are  no  constitutional  symp- 
toms produced  by  this  disease;  when  fever  and  other  general  symptoms 
are  present  they  are  due  to  a  coexisting  or  complicating  affection. 

The  course  of  the  disease  is  usually  benign  and  recovery  may  be  ex- 
pected within  a  week  or  ten  days.  When,  however,  this  condition  occurs 
as  a  complication  of  severe  malnutrition  it  does  not  yield  so  readily  to 
treatment. 

Treatment. — The  preventive  treatment  is  the  same  as  that  given  for 
thrush.  The  local  treatment  consists  in  the  careful  washing  of  the  ulcer 
with  some  mild  alkaline  antiseptic:  a  2  per  cent,  boracic  acid  and  bicar- 
bonate of  soda  solution  may  be  used  for  this  purpose.  The  ulcer  should 
not  be  irritated  by  the  application  of  strong  astringents  or  by  brushing  it 
roughly  with  cloth  or  cotton  for  the  purpose  of  appMng  a  cleansing  solu- 
tion: if  it  is  carefully  exposed,  gentle  irrigation  is  all  that  is  necessary 
for  purposes  of  cleanliness. 

Chlorate  of  potash  is  the  all-important  remedy  in  the  treatment  of  this 
disease;  it  is  believed  by  Forchheimer  and  others  to  act  specifically  in  its 
cure.  One  or  two  grains  of  chlorate  of  potash,  depending  upon  the  age  of 
the  child,  is  to  be  given,  well  diluted,  every  hour  or  two  during  the  waking 
period  for  two  or  three  days ;  thereafter,  if  necessary,  it  should  be  given  at 
longer  intervals.  A  solution  of  chlorate  of  potash  should  also  be  used  at 
intervals  during  the  day  for  irrigating  the  ulcer.  The  chlorate  of  potash 
taken  internally  is  largely  excreted  through  the  saliva,  and  in  this  way  a 
more  or  less  constant  application  of  this  drug  to  the  diseased  parts  is  pro- 


152  STOMATITIS 

duced.  Weak  solutions  of  alum  and  nitrate  of  silver  are  also  very  generally 
recommended,  especially  in  those  cases  that  do  not  yield  readily  to  treat- 
ment. In  my  experience  these  astringents  are  rarely,  if  ever,  necessary.  An 
important  part  of  the  treatment  consists  in  inducing  the  child  to  take 
proper  food,  such  as  milk  and  cereal  mixtures. 

STOMATITIS  GANGRENOSA 

{Noma;  Cancrum   Oris) 

Etiology.— Noma  is  a  severe  infection  most  commonly  beginning  in  the 
mucous  membrane  of  the  mouth  and  resulting  in  more  or  less  extensive 
gangrene  of  the  soft  parts  of  the  face ;  its  definite  clinical  history  indicates 
that  it  is  due  to  some  specific  cause.  Babes  and  Zambolovici  isolated  a 
bacillus  which  they  believe  to  be  etiologically  related  to  this  disease,  and 
the.  bacillus  and  spirillum  of  Vincent  together  with  the  ordinary  pyogenic 


FiQ.  23. — Stomatitis  Gangrenosa,  be- 
fore Perforation. 


Fig.  24. 


-Stomatitis  Gangrenosa,  aft- 
er Perforation. 


organisms  are  associated  with  its  destructive  processes.  Noma  occurs  most 
commonly  between  the  second  and  the  sixth  year  of  life.  It  attacks  children 
whose  vital  powers  have  been  greatly  reduced  by  serious  illness.  It  may 
occur  as  a  sequel  of  ulcerative  stomatitis  and  is  commonly  seen  as  a  com- 
plication of  measles  and,  more  rarely,  of  diphtheria,  typhoid  fever,  scarlet 
fever  and  whooping-cough.  Holt  saw  "five  cases  in  a  single  ward,  all  be- 
ginning in  the  auditory  canal,  which  were  apparently  produced  by  the  use 
of  the  same  syringe  to  clean  the  ears  without  proper  disinfection.  All  of 
these  children  were  suffering  from  whooping-cough  at  the  time." 

Symptomatology. — A  putrid  odor  may  lead  to  the  examination  of  the 


STOMATITIS   GANGRENOSA  153 

mouth,  and  the  diagnosis  is  made  by  the  characteristic  appearances  there 
seen.  On  the  inside  of  the  cheek  a  dark,  necrotic  ulcer,  surrounded  by  an 
infiltrated  and  swollen  area,  may  commonly  be  seen  and  felt,  and  the 
outer  surface  of  the  cheek  is  infiltrated,  producing  a  hard  lump,  over 
which  tlie  skin  may  be  pale  and  not  at  all  sensitive  to  touch.  As  the  infil- 
tration spreads  a  well-defined  dark  or  black,  gangrenous  patch  may  be  seen 
on  the  mucous  membrane.  The  necrosis  slowly  spreads,  the  gangrenous 
process  extends  through  the  cheek,  involving  the  skin.  The  line  of  de- 
marcation between  the  dead  and  the  live  tissue  is  now  well  marked.  Per- 
foration of  the  cheek  results  from  the  dislodgment  of  the  gangrenous  patch, 
and  through  the  opening  the  teeth  or  mucous  membranes  of  the  gums  may 
be  seen.  Very  commonly  the  gums  are  affected,  and  the  bones  beneath  may 
become  necrotic  and  the  teeth  may  come  out.  There  is  little  or  no  pain 
in  this  disease  and  hemorrhages  are  very  unusual.  Strangely  enough  the 
gangrenous  process  is  almost  always  confined  to  one  side  of  the  face ;  rarely 
both  sides  may  be  affected.  As  the  disease  progresses  the  fetor  increases 
and  the  disagreeable  odor  is  almost  unbearable.  In  the  beginning  there  is 
little  to  call  attention  to  the  serious  character  of  the  disease;  the  child 
may  be  playful,  sit  up  in  bed  and  take  nourishment,  but  as  the  disease 
progresses  a  septic  temperature  becomes  more  marked.  The  fever  may 
reach  104°  or  105°  F.  The  pulse  becomes  weak,  prostration  grows  apace, 
and  the  child  finally  dies  from  exhaustion,  or  from  some  complication  such 
as  bronchopneumonia. 

Prognosis. — The  prognosis  is  very  grave.  The  great  majority  of  these 
cases  die.  Fifteen  or  twenty  per  cent,  of  them  recover  after  prolonged  ill- 
ness, and  the  resulting  deformity  is  great. 

Treatment. — There  is  little  in  the  way  of  medical  treatment  beyond 
careful  feeding  and  the  use  of  whiskey,  brandy  and  heart  tonics  to  keep 
up  the  general  strength  of  the  child;  the  gangrenous  parts  should  be  kept 
as  clean  as  possible  by  antiseptic  washes.  In  a  small  percentage  of  the 
cases  nature  effects  a  cure.  Diphtheria  antitoxin  has  been  used  with  some 
success  in  cases  due  to  the  Klebs-Loffler  bacillus.  In  gangrene,  following 
tonsillitis,  antistreptococcic  serum  may  do  good. 

Noma  should  be  classified  as  a  surgical  disease,  and  as  soon  as  the 
diagnosis  has  been  accurately  established  the  case  should  be  referred  to  a 
surgeon  for  treatment.  Excision  of  the  gangrenous  part  should  be  thorough ; 
the  tissues  should  be  removed  well  beyond  the  gangrenous  line  and  all  dis- 
eased bone  taken  out;  the  surgical  wound  thus  made  should  be  cauterized 
and  thereafter  dressed  according  to  approved  surgical  methods.  Under  this 
treatment  the  chances  for  recovery  are  improved,  but  at  best  the  condition- 
is  a  desperate  one  and  desperate  chances  should  be  taken,  to  save  life. 


164  DISEASES  OF  THE  MOUTH  AND  ESOPHAGUS 


CHAPTEK  XVII 

OTHER    DISEASES    OF    THE    MOUTH    AND    DISEASES    OF    THE 

ESOPHAGUS 

BEDNAR'S  APHTHiE 

This  is  a  condition  of  little  pathological  importance.  It  consists  of  two 
small,  rounded,  grayish- white  ulcers  about  the  size  of  a  pea,  symmetrically 
located  on  the  hamular  processes  of  the  palate  bone,  at  an  equal  distance 
from  the  palatine  ridge.  They  produce  no  constitutional  symptoms,  but  are 
slightly  painful  to  the  touch  and  may  therefore  interfere  with  the  taking 
of  food.  They  are  believed  to  be  produced  by  some  injury  to  the  mucous 
membrane,  which  is  especially  prominent  and  delicate  over  the  hamular 
processes.  '  The  exciting  causes  are  too  vigorous  mouth-washing  and  the 
prolonged  sucking  of  rubber  nipples  and  pacifiers.  This  condition  occurs 
only  during  the  first  weeks  of  life. 

Treatment.— The  condition  is  a  benign  one  and  requires  no  treatment 
other  than  the  irrigation  of  the  mouth  with  sterile  water  or  a  2  per  cent, 
solution  of  boric  acid.  The  ulcers  are  not  to  be  rubbed  or  cleansed  with 
gauze  or  cotton ;  they  should  be  let  alone.  Even  the  untreated  cases  termi- 
nate in  spontaneous  recovery.  To  hasten  the  cure  it  has  been  recommended 
that  the  ulcers  be  lightly  touched  with  a  1  per  cent,  solution  of  nitrate  of 
silver  once  a  day. 

PERLECHE 

Perleche  is  an  ulcerative  process,  probably  nonspecific  in  character, 
which  confines  itself  to  the  angles  of  the  mouth.  It  occurs  throughout 
childhood,  but  is  perhaps  most  common  about  the  second  or  third  year  of 
life.  It  is  commonly  seen  in  children  suffering  from  glandular  tuberculosis 
and  other  forms  of  general  malnutrition.  Lack  of  cleanliness  in  the  care 
of  food  utensils  and  unhygienic  surroundings  predispose  to  this  infection. 
It  may  be  transferred  to  other  members  of  the  family  by  direct  contact,  as 
in  kissing,  or  by  indirect  means,  such  as  the  use  of  common  food  utensils 
and  toilet  articles  without  proper  sterilization.  One  corner  of  the  mouth 
is  nearly  always  infected  from  the  other  by  the  tongue  transferring  the  con- 
tagion.   This  accounts  for  the  bilateral  character  of  this  disease. 

Symptomatology. — The  corners  of  the  mouth  are  the  sites  of  ulcers 
which  first  make  their  appearance  in  the  form  of  slight  fissures;  later  the 
ulceration  extends  and  is  covered  by  a  sticky  exudate  and  the  surrounding 
parts  are  swollen  and  indurated.  Pain  and  slight  bleeding  are  produced 
by  stretching  the  corners  of  the  mouth  and  forcible  removal  of  the  scab 
leaves  a  raw  and  bleeding  surface.  From  these  ulcers  there  radiate  from 
the  corners  of  the  mouth  well-marked  fissures,  giving  to  this  condition  a 
characteristic  appearance,  which  cannot  be  mistaken  for  any  other  form 


GEOGEAPHICAL   TONGUE  155 

of  ulceration  except  the  syphilitic  ulcer  which  occurs  at  this  point.  The 
differentiation  between  these  two  conditions,  however,  may  be  made  by  the 
existence  or  absence  of  other  syphilitic  symptoms. 

Treatment. — In  the  great  majority  of  cases  even  the  untreated  cases 
terminate  in  spontaneous  recovery ;  in  a  few  instances,  however,  the  disease 
may  continue  for  months.  The  scabs  covering  the  ulcers  should  be  softened 
by  the  application  of  a  1  per  cent,  boracic  acid  ointment;  after  a  number 
of  days  they  may  be  removed  without  producing  much  irritation.  The 
surfaces  thus  exposed  should  be  painted  two  or  three  times  a  day  with  a 
2  per  cent,  nitrate  of  silver  solution.  Following  the  application  of  the 
silver  the  ulcers  should  be  washed  and  some  such  sedative  ointment  as  the 
following  should  be  applied :  Bismuth  subnitrate,  3i,  acid  salicyl.,  grs.  xx, 
lanolin,  q.  s.  ad  §i. 

ELONGATED  UVULA 

An  elongated  uvula  may,  by  irritating  the  base  of  the  tongue  and  the 
pharynx,  produce  a  most  persistent  and  irritating  cough,  which  may  be 
greatly  aggravated  when  the  child  is  lying  down.  As  a  result  of  constant 
coughing  the  child  loses  sleep  and  becomes  more  or  less  nervous  and  hys- 
terical, and  this  nervousness  in  turn  may  increase  the  paroxysms  of  cough- 
ing. When  this  symptom  group  occurs  in  children  having  a  normal  tem- 
perature and  with  no  physical  signs  in  the  throat  or  lungs  to  account  for  it 
the  uvula  should  be  inspected,  and  if  it  be  found  elongated  to  such  an 
extent  that  it  can  readily  come  in  contact  with  the  pharynx  and  tongue,  it 
should  be  amputated.  Clipping  off  the  uvula  is  a  simple  operation  which 
effectually  terminates  the  existing  attack  and  prevents  recurrences. 

Astringent  gargles  or  astringents  applied  in  other  ways  to  the  uvula 
are  effective  in  relieving  the  attack.  A  twenty  per  cent,  solution  of  alum  or 
5  to  10  per  cent,  solution  of  tannic  acid,  when  applied  to  the  uvula, 
usually  causes  it  to  contract  and  relieves  the  irritating  cough.  A  good- 
sized  dose  of  bromid  of  potash  should  be  given  at  the  same  time. 

GEOGRAPHICAL  TONGUE 

(Ringworm  of  the  Tongue;  Desquamative  Glossitis;  Wandering  Rash  of 

the  Tongue) 

Symptomatology. — One  or  the  other  of  these  names  is  used  to  describe 
a  condition  of  the  tongue  which  has  little  or  no  pathological  significance, 
but  the  very  remarkable  change  which  it  produces  in  the  surface  of  the 
tongue  always  attracts  attention  and  calls  for  explanation.  There  appears 
usually  on  the  dorsum  a  grayish-white  patch  distinctly  outlined  by  the  sur- 
rounding pink  mucous  membrane;  as  this  increases  in  size  it  takes  on  a 
characteristic  appearance;  in  the  center  it  becomes  more  or  less  denuded 
of  the  superficial  epithelial  layers,  which  gives  it  a  reddish  color.  As  these 
red  patches  increase  in  number  they  may  coalesce  and  give  to  the  tongue  a 
geographical  appearance.    If  the  scrapings  from  these  elevated  borders  be 


156  DISEASES  OF  THE  MOUTH  AND  ESOPHAGUS 

placed  under  the  microscope,  in  addition  to  the  epithelium  and  detritus  thus 
obtained  there  will  be  found  cocci,  sarcinae  and  other  microorganisms,  none 
of  which  have  as  yet  been  definitely  associated  with  the  etiology  of  this  con- 
dition. It  occurs  most  commonly  from  the  first  to  the  fifth  year  of  life, 
but  it  may  be  seen  at  any  time  during  infancy  and  childhood. 

Treatment— This  condition  is  of  no  diagnostic  or  pathologic  impor- 
tance. It  may  occur  in  perfectly  normal  children  and  its  presence  furnishes 
no  clue  to  the  existence  of  any  constitutional  or  local  disorder.  It  requires 
no  treatment,  although  painting  the  tongue  with  5  or  10  per  cent,  solu- 
tions of  nitrate  of  silver  and  afterward  thoroughly  irrigating  the  mouth 
with  a  mild  alkaline  antiseptic  have  been  recommended.  This  condition 
may  persist  for  months  or  years  and  then  disappear,  or  it  may  continue 
throughout  life. 

TONGUE-TIE 

A  short  frenum  which  binds  the  tongue  to  the  floor  of  the  mouth  is 
the  cause  of  this  deformity.  It  interferes  with  sucking  and  articulation  and 
prevents  the  protrusion  of  the  tongue  beyond  the  gums. 

The  diagnosis  of  tongue-tie  in  backward  children  is  frequently  made, 
when  it  does  not  exist,  to  account  for  their  defects  in  articulation.  The 
treatment  consists  in  cutting  the  frenum  and  separating  the  tissues  far 
enough  back  to  liberate  the  tongue. 

HARE-LIP 

In  the  formation  of  the  tipper  lip  a  central  process  unites  with  two 
lateral  processes  just  beneath  the  nostrils.  When  this  union  fails  to  occur 
the  lip  remains  fissured  or  slit  on  one  or  both  sides,  producing  a  single  or 
double  hare-lip.  The  deformity  may  vary  from  a  slight  indentation  to  a 
fissure  completely  separating  the  lip  and  extending  into  the  nostril.  When 
this  deformity  occurs  on  both  sides  it  is  much  more  difficult  to  overcome 
by  surgical  interference. 

Hare-lip  greatly  interferes  with  the  feeding  of  the  infant  and  sometimes 
makes  nursing  impossible.  It  is  important  in  all  cases  to  encourage  nursing 
and  supplement  the  feeding  by  pumping  out  the  mother's  milk  and  feeding 
it  with  a  dropper.  As  soon  as  the  nutritional  processes  of  the  body  have 
been  well  started  a  surgical  operation  for  the  relief  of  this  condition  is 
advisable.    This  may  usually  be  done  about  the  fourth  week  of  life. 

CLEFT-PALATE 

Cleft-palate  is  commonly  associated  with  hare-lip  and  not  infrequently 
with  other  congenital  deformities.  Heredity  is  the  most  common  etiological 
factor;  not  infrequently  more  than  one  case  occurs  in  the  same  family. 
This  deformity  is  said  to  occur  more  commonly  in  boys;  I  observed,  how- 
ever, one  family  in  which  there  were  four  girls  all  born  with  cleft-palates 
and  hare-lips,  and  three  boys  entirely  free  from  these  deformities.     The 


PERIESOPHAGEAL  ABSCESS  157 

fissures  may  involve  only  the  soft  palate  or  both  the  hard  and  soft  palate. 
It  results  from  failure  of  the  palatal  arches  to  unite.  Cleft-palate,  especially 
when  associated  with  hare-lip,  is  a  serious  deformity  and  not  infrequently 
interferes  to  such  an  extent  with  the  taking  of  food  that  the  infant  dies 
from  marasmus.  This  deformity  makes  it  difficult  to  keep  the  infant's 
mouth  clean  and  thereby  predisposes  to  thrush. 

The  early  treatment  of  these  cases  consists  in  devising  ways  and  means 
by  which  the  infant  may  be  fed  with  breast  milk.  By  pumping  the  breasts 
of  a  wet  nurse  milk  may  be  secured,  which  may  be  fed  to  the  baby  by  a 
spoon  or  dropper.  The  greatest  care  should  be  exercised  to  keep  the  in- 
fant's mouth  clean  by  gently  washing  it  with  warm  water.  If  the  operation 
for  hare-lip  is  successfully  made  during  the  second  month,  there  will  be 
less  difficulty  in  feeding  and  the  operation  for  cleft-palate  may  be  deferred 
until  the  end  of  the  second  year.  As  the  treatment,  however,  is  essentially 
surgical,  both  the  time  and  the  nature  of  the  operation  may  be  left  to  the 
judgment  of  the  surgeon. 

ESOPHAGITIS 

Esophagitis  is  an  inflammation  of  the  esophagus  commonly  due  to  the 
swallowing  of  caustic  alkalies  or  mineral  acids  or  to  the  extension  of  some 
inflammation  from  the  pharynx. 

Symptomatology. ^In  caustic  esophagitis  the  stomach  is  usually  in- 
volved; there  are  great  pain,  restlessness,  crying,  and  difficulty  in  swallow- 
ing; any  attempt  at  taking  food  or  water  aggravates  these  symptoms. 
Nausea  and  vomiting  are  common  and  the  vomited  matter  may  contain 
blood.  An  examination  of  the  mouth  and  throat  shows  that  these  mucous 
membranes  are  swollen  and  inflamed.  The  severity  of  the  symptom  group 
depends  upon  the  quantity  and  concentration  of  the  caustic  fluid  swal- 
lowed. In  severe  cases  the  injury  to  the  stomach  may  cause  a  rapidly  fatal 
termination.  In  the  milder  cases  of  esophagitis  the  above  symptom  group 
is  less  severe  and  may  gradually  subside;  convalescence  resulting  either  in 
complete  recovery  or  in  stricture  of  the  esophagus. 

Treatment. — This  consists  in  relieving  the  pain  when  necessary  by  hypo- 
dermic injections  of  morphin  and  in  the  giving  of  nutrient  and  saline 
enemata  until  the  child  is  able  to  swallow  milk  and  water.  Later  surgical 
intervention  may  be  necessary  to  relieve  the  esophageal  stricture. 

PERIESOPHAGEAL  ABSCESS 

Periesophageal  abscess  is  usually  due  to  suppuration  of  lymph  nodes, 
disease  of  the  spine  or  to  foreign  bodies;  tuberculosis  is  the  most  common 
cause. 

The  symptoms  depend  largely  upon  the  location  of  the  abscess  and  are 
usually  those  of  esophageal  stenosis.  When  located  high  up,  the  trachea, 
larynx  and  recurrent  laryngeal  nerve  may  be  involved.     In  these  cases 


158  DISEASES  OF  THE   STOMACH 

tliere  may  be  dyspnea,  aplionia  and  violent  attacks  of  coughing.     The  ab- 
scess may  cause  death  by  opening  into  the  esophagus  or  trachea. 

The  prognosis  is  bad;  si)ontaneous  rupture  may  rarely  result  in  re- 
covery.   Surgical  intervention  is  advisable  in  selected  cases. 

BRANCHIAL  CYSTS 

Branchial  cysts  are  cystic  tumors  having  their  origin  in  the  faulty 
closure  of  the  branchial  clefts  of  fetal  life.  They  are  usually  located  in 
the  anterior-lateral  surfaces  of  the  neck  in  close  proximity  with  the  great 
vessels.  Tliis  rare  form  of  cystic  tumor  yields  readily  to  radical  surgical 
treatment. 

CONGENITAL  MALFORMATIONS  OF  THE  ESOPHAGUS 

Griffith  notes  the  following  forms  of  congenital  malformations  of  the 
esophagus:  "1.  Total  absence  of  the  esophagus.  2.  Partial  or  complete 
doubling  of  esophagus.  3.  Tracheoesophageal  fistula  without  other  lesion 
of  the  esophagus.  4.  Congenital  stenosis,  5.  Congenital  dilatation.  6.  Ob- 
literation of  the  esophagus  in  only  a  portion  of  its  extent  unaccompanied 
by  fistula.  7.  Obliteration  of  a  portion  of  the  esophagus  with  tracheo- 
esophageal (or  bronchoesophageal)  fistula. 

"Treatment. — This  is  entirely  discouraging.  Cases  of  stenosis  have  re- 
covered, but  all  instances  of  complete  obstruction  have  died.  The  weak- 
ness of  the  child  and  its  early  age  make  operative  interference  a  question- 
able procedure;  yet  gastrostomy  offers  the  only  hope.  This  operation  was 
first  done  in  the  case  of  Steel,  and  has  been  performed  since  then  in  those 
of  Hoffmann,  Hoppich,  Villemin,  Kirmisson.  and  Dickie.  The  child 
should  be  kept  on  its  side  to  allow  the  mucus  to  flow  from  the  mouth.  It 
may  be  fed  through  the  gastric  fistula.  Should  it  recover  an  effort  may 
later  be  made  to  repair  the  esophagus  by  a  lateral  operation  in  the  neck. 
This  indeed  was  attempted  unsuccessfully  in  Hoffmann's  case  as  a  primary 
operation  and  gastrostomy  resorted  to  later." 


CHAPTER  XVin 
DISEASES  OF  THE  STOMACH 

ACUTE  GASTRIC  INDIGESTION 

Etiologfy. — The  causes  of  tliis  condition,  especially  in  the  infant,  may 
be  grouped  under  two  headings:  first.  Physiological  Gastric  Incompetency; 
second,  Improper  Food. 

Physiological  Gastric  Incompetency. — Physiological  gastric  incom- 
petency may  be  inherited  or  acquired  ;  it  is  most  pronounced  during  the  hot 
summer  months.     In  feeti^  malnourished,  neurotic  infants  there  may  be 


ACUTE   GASTRIC  INDIGESTION  159 

such  a  predisposition  to  acute  gastric  indigestion  that  slight  causes,  such 
as  rapid  eating,  coddling  and  exercise  directly  after  meals,  slight  changes 
in  the  food  formula,  dentition,  nervous  excitement,  or  the  swallowing  of 
mucus  in  catarrhal  conditions  of  the  respiratory  passages,  may  cause  this 
trouhle.  It  is  important  therefore  in  every  case  of  acute  gastric  indigestion 
to  consider  not  only  the  apparent  exciting  caiises,  but  also  the  probable  in- 
fluence which  the  physiological  gastric  incompetency  of  the  individual  in- 
fant may  play  in  the  production  of  this  symptom  group. 

Improper  Food. — The  most  common  exciting  causes  are  to  be  found 
either  in  tlie  quantity  or  in  the  quality  of  the  food.  It  may  occur  in  breast- 
fed babies  from  irregularities  in  nursing;  that  is  to  say,  giving  too  much 
food  at  too  short  intervals.  The  breast  milk  itself,  however,  may  cause  in- 
digestion by  changes  in  its  composition  produced  by  nervous  excitement  on 
the  part  of  the  wet  nurse,  or  by  the  character  of  her  food,  or  by  the  un- 
hygienic life  she  may  be  leading.  Artificial  food  unsuited  to  the  digestive 
capacity  of  the  child,  or  properly  prepared  food  given  in  too  great  quantities 
or  at  too  short  intervals,  are  the  most  common  causes  of  acute  gastric  in- 
digestion. Rapidly  increasing  the  strength  of  the  food  formula,  especially 
in  fat  and  protein,  or  changing  from  one  of  the  proprietary  foods  to  a 
modified  milk  formula  are  common  exciting  causes.  In  older  children  the 
taking  of  improper  food,  or  food  beyond  the  digestive  capacity  of  the  child 
may  produce  very  severe  attacks  of  gastric  indigestion.  Candy,  pastry, 
fruit,  berries  and  vegetables  given  to  infants  and  children  whose  age  and 
digestive  capacity  wholly  unfit  them  for  the  taking  of  these  foods  are  com- 
mon causes  of  gastric  indigestion. 

Symptomatology. — The  attack  is  usually  ushered  in  with  colic,  nausea, 
irritability,  fretfulness,  restlessness  and  a  slight  elevation  of  temperature. 
The  appetite  is  lost,  the  tongue  is  coated  and  after  a  time  vomiting  occurs, 
the  vomitus  containing  undigested  food  that  has  been  perhaps  retained  in 
the  stomach  for  many  hours.  The  irritability  of  the  stomach  and  vomiting 
may  recur  at  intervals  for  a  number  of  hours,  and  the  taking  of  food  may 
prolong  and  aggravate  these  symptoms.  Following  the  vomiting  the  pain, 
fever  and  nervous  symptoms  gradually  subside.  During  the  next  few  days 
the  stomach  is  irritable  and  vomiting  is  easily  provoked,  and  more  or  less 
intestinal  irritation  with  diarrhea  is  present.  In  young,  delicate  and  mal- 
nourished infants  all  of  these  symptoms  may  be  greatly  exaggerated.  The 
fever  may  run  as  high  as  104°  or  105°  F.  and  gre^t  prostration,  extreme 
pallor,  great  nervous  irritability  and  even  convulsions  may  occur.  But  in 
these  severe  cases,  as  in  the  milder  ones,  the  emptying  of  the  stomach  by 
vomiting  and  the  unloading  of  the  intestinal  canal  by  a  cathartic  quickly 
cause  a  subsidence  of  all  the  acute  symptoms,  leaving  the  child  weak,  and 
suffering  from  a  gastric  irritability  from  which  it  slowly  convalesces  under 
careful  treatment.  In  older  children  the  fever  is,  as  a  rule,  absent  and  the 
nervous  symptoms  are  much  less  marked,  but  gastric  colic  or  severe  gas- 
tralgia  is  a  much  more  common  symptom  than  it  is  in  the  infant. 

Prognosis. — The  prognosis  is  good  and  there  is  rarely  any  danger  from 
13 


IGO  DISEASES  OF  THE   STOMACH 

gastric  indigestion  except  in  young  and  very  delicate  infants,  and  then  the 
danger  is  conuiionly  due  to  convulsions.  If  the  stomach  is  emptied  and 
food  is  stopped  the  "infant  should  be  convalescent  within  three  or  four  days. 

Treatment. — If  vomiting  has  not  occurred,  and  even  if  it  has  and  there 
is  reason  to  l)elieve  that  the  stomach  has  not  fully  emptied  itself,  it  is  ad- 
visable to  wash  out  the  stomach  with  a  lukewarm  physiological  salt  solu- 
tion; this  procedure  often  arrests  the  nausea  and  vomiting.  Small  doses 
of  calomel  should  be  given,  a  tenth  of  a  grain  every  half  hour  until  one 
grain  is  taken,  and  all  food  should  be  stopped  and  only  sufficient  water 
given  to  administer  the  calomel.  Eest  for  the  stomach  and  quiet  for  the 
infant  during  the  next  few  hours  are  necessary.  After  three  or  four  hours 
a  dose  of  milk  of  magnesia  should  be  given  to  assist  the  calomel  in  its 
action.  Castor  oil,  which  is  likely  to  prolong  the  gastric  irritability,  should 
be  abstained  from.  Commonly  no  other  medication  is  needed  in  these 
cases,  but  if  the  gastric  irritation  is  prolonged,  a  teaspoonful  of  simple 
chalk  mixture  or  lime  water  may  be  given  every  two  or  three  hours,  or 
sodium  bicarbonate  or  compound  chalk  powder  in  2-grain  doses  may  be 
given  in  a  little  water  every  two  hours.  After  some  hours,  when  the  infant 
demands  food,  it  may  be  given  water  to  drink  and  later  barley  water ;  if  the 
infant  be  very  young  the  barley  water  may  be  malted.  Barley  water,  beef 
broth,  beef  juice  and  whiskey  and  water  should  constitute  the  nourishment 
for  twenty-four  or  thirty-six  hours,  and  then  small  quantities  of  fat-free 
cow's  milk  should  be  added  to  the  barley  water,  and  as  the  child  convalesces 
it  may  gradually  return  to  its  original  diet.  In  breast-fed  babies  the  breast 
milk  may  be  carefully  resumed  after  the  stomach  has  been  rested  for  twelve 
or  twenty-four  hours. 

In  older  children  the  treatment  is  somewhat  different ;  the  gastric  pain 
must  be  relieved  by  hot  applications  to  the  stomach,  spirits  of  chloroform 
and  whiskey  internally,  and  if  the  child  has  not  vomited  an  emetic  may  be 
given,  preferably  the  syrup  of  ipecac.  Later,  as  the  nausea,  vomiting  and 
pain  subside,  a  saline  cathartic  should  be  given,  the  stomach  should  be  rested 
and  the  child  dieted  according  to  its  age  and  physical  condition.  The  fol- 
lowing prescription  is  of  value  during  this  period : 

]^     Acidihydrochlorici  dil 3  j 

Pepsin  puri grg    ^y 

Glycerin!    t  jj 

Aquffi  destillatae  ad ?  jj 

Sig.  Teaspoonful  after  eating  for  a  child  six  years  of  age. 

ACUTE  GASTRITIS 

Etiology  and  Pathology. — Xoxcorrosive  Form. — Acute  gastritis  is 
very  commonly  a  sequel  of  a^ute  gastric  indigestion.  In  feeble,  malnour- 
ished, neurotic  children  this  sequence  is  most  commonly  noted.  The  pro- 
longed heat  of  summer  may,  by  reducing  the  vitality  of  the  infant,  pre- 
dispose it  to  attacks  of  gastritis.  Spoiled  food,  especially  milk  which  has 
undergone  bacterial  contamination,  is  a  potent  factor.     Gastritis  is  also 


ACUTE   GASTRITIS  161 

a  common  complication  of  the  acute  infections,  especially  influenza,  measles 
and  whooping-cough.  Acute  enteritis,  whatever  may  be  its  causes,  is  very 
commonly  complicated  with  acute  gastritis,  and  an  acute  gastritis  which 
does  not  yield  promptly  to  treatment  is  almost  always  followed  by  more  or 
less  enteritis. 

In  the  ordinary  form  of  acute  gastritis  the  stomach  is  found  to  con- 
tain a  thick,  tenacious  mucus,  closely  adherent  to  the  mucous  membrane, 
and  this  mucus  may  be  mixed  with  a  dark  granular  substance  which  analy- 
sis proves  to  be  blood.  The  mucous  membrane  presents  the  appearance  of 
an  acute  catarrhal  inflammation.  It  is  hyperemic,  swollen,  thickened,  is 
infiltrated  with  round  cells,  shows  a  superficial  loss  of  epithelium  and  may 
be  dotted  with  petechial  hemorrhages.  Small  ulcers,  similar  to  those  which 
occur  in  gastroenteritis,  may  be  present  in  the  more  severe  cases;  a  pseudo- 
membrane  rarely  occurs. 

Corrosive  Gastritis. — Corrosive  gastritis  differs  radically  in  its  etiol- 
ogy and  clinical  history  from  ordinary  gastritis.  This  severe  form  of  in- 
flammation of  the  stomach  may  be  excited  by  such  caustic  poisons  as  am- 
monia, carbolic  acid,  mineral  acids,  arsenic  and  other  corrosive  poisons. 
In  this  condition  the  mucous  membrane  is  ulcerated,  and  the  extent  of  these 
ulcerations  will  depend  upon  the  severity  of  the  caustic  action;  they  may 
even  cause  perforation.  In  milder  cases,  where  the  caustic  poison  is  not  so 
concentrated  or  where  the  poison  is  taken  into  a  full  stomach  which  is 
quickly  emptied  by  vomiting,  the  ulcerations  may  not  be  so  extensive  and 
the  patient  may  recover.  Recovery  may  be  followed  by  a  cicatricial  con- 
traction of  the  stomach,  the  pharynx  or  the  esophagus,  producing  deformi- 
ties with  more  or  less  stenosis  of  the  esophagus  or  pylorus.  A  severe 
esophagitis  and  more  or  less  pharyngitis  are  commonly  present. 

Symptomatology. — In  ordinary  cases,  not  corrosive,  the  beginning  of 
the  attack  cannot  be  distinguished  from  an  acute  gastric  indigestion,  except 
perhaps  in  the  severity  of  the  symptoms.  Nausea,  vomiting,  pain,  fever  and 
prostration  mark  the  onset  of  the  disease.  The  vomiting,  which  is  an  early 
symptom,  is  very  severe;  the  stomach  is  emptied  of  its  contents,  but  the 
nausea  and  vomiting  continue,  resulting  in  the  expelling  of  small  quanti- 
ties of  sour  mucus  or  bilious  matter  which  may  be  tinged  with  blood;  the 
vomitus  unlike  that  found  in  Recurrent  Vomiting  never  contains  free 
hydrochloric  acid.  The  taking  of  food  and  water  greatly  aggravates  these 
symptoms.  Pain  in  the  stomach  is  commonly  present  in  older  children, 
and  after  a  few  hours  is  followed  by  epigastric  tenderness.  The  fever  is 
especially  high  in  infants  and  may  within  the  first  few  hours  reach  104° 
or  105°  F.,  but  after  the  stomach  has  emptied  itself  it  gradually  subsides. 
Convulsions  may  occur  in  young  infants  and  is  a  dangerous  complication 
in  weaklings.  Prostration  is  great,  especially  early  in  the  disease,  but  grad- 
ually subsides  under  proper  treatment.  The  tongue  is  coated,  the  breath 
is  foul,  and  on  the  second  or  third  day  there  is  usually  a  complicating  diar- 
rhea. In  favorable  cases  where  treatment  is  begun  early,  convalescence 
should  be  established  between  the  third  and  the  sixth  day.     But  in  cases 


162  DISEASES  OF  THE   STOMACH 

that  are  badly  managed  and  improperly  fed  before  convalescence  is  estab- 
lished, relapses  occur,  and  the  disease  may  in  this  way  be  prolonged  or  con- 
verted into  a  gastroenteritis.  The  above  clinical  picture  applies  to  infants. 
In  older  children  the  fever,  vomiting  and  prostration  are  much  less  severe 
and  convulsions  rarely  occur,  but  the  gastric  colic  is  commonly  more  marked. 

In  the  CORROSIVE  form  of  this  disease,  that  produced  by  caustic  poisons, 
all  of  the  above  symptoms  are  greatly  exaggerated.  The  pain  is  intense, 
the  vomited  matter  commonly  contains  blood,  and  prostration  is  extreme; 
these  symptoms  may  continue  for  a  number  of  days,  resulting  in  death. 
In  milder  cases  there  is  a  prolonged  convalescence  covering  weeks  and 
sometimes  months,  resulting  in  the  deformities  and  contractures  above 
mentioned.  In  this  form  of  the  disease  there  is  also  great  pain  in  swallow- 
ing due  to  the  complicating  pharyngitis  and  esophagitis. 

Treatment. — The  early  treatment  of  the  noxcorrosive  form  of  acute 
gastritis  is  the  same  as  that  of  acute  gastric  indigestion.  The  stomach 
may  be  emptied  by  lavage  if  the  vomiting  has  not  accomplished  this  pur- 
pose. An  enema  should  be  given  and  absolute  quiet  for  the  patient  and  rest 
for  the  stomach  insisted  upon.  Older  infants  and  children  may  get  more 
or  less  comfort  and  satisfaction  in  being  allowed  to  suck  small  pieces  of  ice 
held  in  a  cloth,  but  no  food  or  medication  is  indicated  for  some  hours  after 
the  onset  of  the  attack.  After  vomiting,  however,  has  subsided,  a  dose  of 
milk  of  magnesia  may  be  given,  and,  if  necessary,  water  or  barley  water  may 
be  given  in  small  quantities.  On  the  second  day  of  the  disease  the  diet 
should  consist  of  barley  water,  meat  juice  and  small  quantities  of  Nestle's 
food  to  which  a  diastase  has  been  added.  On  the  third  day,  in  addition  to 
the  above-named  foods,  whey  may  be  given.  On  the  fourth  day,  if  the 
child's  convalescence  has  been  satisfactory,  a  small  quantity  of  skimmed 
milk  may  be  added  to  the  whey  or  Nestle's  food  and  from  this  time  the 
return  to  cow's  milk  should  be  very  gradual.  If  the  infant  happens  to  be 
breast-fed  it  may  return  to  the  breast  milk  on  the  third  day.  In  very 
young  and  delicate  bottle-fed  infants  it  may  be  advisable  to  hasten  con- 
valescence by  obtaining  a  wet  nurse  on  the  third  or  fourth  day  of  the 
disease.  Throughout  the  attack  the  bowels  must  be  kept  open;  this  may 
be  accomplished  by  calomel,  milk  of  magnesia  and  enemata.  It  is  ad- 
visable in  all  conditions  where  the  stomach  is  inflamed  to  especially  avoid 
fats  or  oils  either  in  the  form  of  food  or  medicines.  For  this  reason  castor 
oil  is  not  advisable  as  a  cathartic,  and  cream  is  not  to  be  recommended  as 
a  food  until  convalescence  is  well  established. 

Other  medication  than  that  above  mentioned  is  rarely  necessary  in 
cases  of  simple  gastritis  in  infants,  but  if  the  vomiting  and  gastric  irrita- 
tion persist  half-teaspoonful  doses  of  simple  chalk  mixture  may  be  given 
at  intervals  of  one  or  two  hours,  or  compound  chalk  powder  in  2  or  3-grain 
doses  may  be  used.  In  older  children  it  may  be  necessary  to  make  hot  ap- 
plications to  the  stomach  for  the  relief  of  pain  and.  after  the  stomach  has 
been  thoroughly  emptied,  to  give  small  doses  of  bismuth  and  sometimes 
paregoric,  put  up  in  chalk  mixture,  for  the  relief  of  the  pain  and  gastric 


DILATATION   OF   THE    STOMACH  163 

irritation,  but  the  bismuth  and  paregoric  should  be  dispensed  with  as  soon 
as  the  special  indications  for  their  use  have  disappeared. 

In  CORROSIVE  GASTRITIS  it  is  absolutely  necessary  to  empty  the  stomach 
as  soon  as  possible  with  some  kind  of  an  emetic,  such  as  the  syrup  of  ipecac. 
After  this  has  been  accomplished,  hot  applications  should  be  made  to  the 
stomach  and  morphin  should  be  given  hypodermically  for  the  relief  of  pain. 
A  solution  of  muriate  of  cocaine  in  1/30-gr.  doses  may  be  given  every 
hour  for  three  or  four  hours.  Following  this  the  pain  and  irritation  of  the 
stomach  may  be  relieved  by  chalk  mixture  containing  small  doses  of  pare- 
goric or  morphin,  and  the  child  must  be  kept  alive  by  hypodermoclysis  of 
physiological  salt  solution  and  by  the  administration  through  the  bowel  of 
physiological  salt  solution,  whiskey  and  nutrient  enemata.  The  stomach 
is  to  have  as  long  a  period  of  rest  as  possible.  In  some  instances  it  may 
be  necessary  to  abstain  from  food  of  all  kinds  for  four  or  five  days,  allow- 
ing the  child  on  the  second  or  third  day  small  quantities  of  water.  When 
the  gastric  ulceration  permits  the  administration  of  food  the  dietetic  man- 
agement of  the  case  is  the  same  as  that  just  given  in  acute  gastritis,  except 
that  one  must  progress  more  slowly  with  the  feeding  and  that  milk  may 
have  to  be  abstained  from  for  a  period  of  four  or  five  weeks. 

DILATATION   OF  THE  STOMACH 

Etiology.  — In  infancy  the  walls  of  the  stomach  are  thin  and  the  muscu- 
lar resistance  slight.  These  anatomical  peculiarities  predispose  to  dilatation. 
Rickets,  chronic  gastritis,  syphilis,  anemia  and  general  malnutrition  still 
further  weaken  the  walls  of  the  stomach,  which  makes  it  possible  for  slight 
causes  to  produce  distention  and  permanent  dilatation.  The  most  com- 
mon exciting  cause  is  the  giving  of  food  in  large  quantities  at  short  in- 
tervals. If  an  infant  four  months  of  age  is  fed  six  or  eight  ounces  of  food, 
or  all  it  will  take,  when  on  account  of  its  malnutrition  it  should  be  fed  only 
three  or  four  ounces  at  intervals  of  three  or  four  hours,  it  is  evident  that 
gastric  distention  and  permanent  dilatation  may  result.  Chronic  gastric 
indigestion  and  chronic  gastric  catarrh  are  also  common  causes  of  dilatation. 

Symptomatology. — In  the  beginning,  vomiting,  gastric  pain,  tenderness 
and  the  other  symptoms  of  chronic  gastric  indigestion  are  present,  and 
general  malnutrition,  great  emaciation,  marked  anemia  and  profound 
asthenia  gradually  develop. 

Diagnosis. — The  diagnosis,  however,  is  made  by  the  physical  examina- 
tion. The  abdomen  is  distended  and  tympanitic,  especially  in  the  epigastric 
region.  The  quantity  of  food  which  the  infant  takes  may  indicate  dilata- 
tion, ^^^len  the  stomach  is  full  its  lower  outline  may  be  mapped  out  by 
percussion  if  the  infant  is  held  in  an  upright  position ;  if  this  dull  outline 
reaches  nearly  to  the  umbilicus  the  stomach  is  dilated,  if  it  reaches  below 
the  umbilicus,  it  is,  according  to  Holt,  much  dilated.  After  the  stomach 
has  been  washed  out  it  may  be  inflated  by  pumping  air  into  it  with  a 
stomach  tube;  in  this  way  the  distended  stomach  may  be  outlined  against 


164  DISEASES  OF  THE   STOMACH 

the  tliin  abdominal  wall  and  the  limits  of  its  tympanitic  note  be  marked 
out  by  percussion.  By  some  one  of  the  above  methods  one  can,  as  a  rule, 
determine  whether  or  not  the  stomach  is  dilated,  but  the  outlining  of  the 
infantile  stomach  is  after  all  more  difficult  in  practice  than  it  is  in  theory. 

Prognosis. — The  above  description  applies  only  to  simple  dilatation  pro- 
duced l)y  the  etiological  factors  given  above  and  does  not  apply  to  the  forms 
of  dilatation  which  occur  from  organic  stricture  of  the  pylorus.  The  prog- 
nosis, therefore,  depends  largely  upon  the  severity  of  the  underlying  predis- 
posing causes;  if  these  are  present  in  a  marked  degree  it  is  very  much 
more  unfavorable.  If,  however,  the  constitutional  disorders  are  not  such 
as  to  produce  a  profound  malnutrition  then  the  prognosis  under  proper 
treatment  is  comparatively  good. 

Treatment. — The  treatment  is  largely  dietetic  and  is  practically  the 
same  as  that  given  for  chronic  gastritis.  The  food  should  be  carefully  se- 
lected to  suit  the  individual  infant ;  breast  milk,  whey  and,  where  the  child 
is  altogether  bottle-fed,  small  quantities  of  fat-free  milk  combined  with  a 
malted  cereal  mixture  may  be  recommended.  Great  care  as  to  diet,  over  a 
long  period  of  time,  is  necessary  to  obtain  success  in  these  cases,  and  it  is 
especially  advisable  that  the  food  should  be  given  at  rather  longer  intervals 
and  in  rather  smaller  quantities  than  the  weight  and  age  of  the  baby  would 
justify  under  normal  conditions.  Most  important  also  is  the  hygienic  man- 
agement ;  the  infant  should  have  as  much  fresh  air  and  sunlight  as  possible, 
and,  if  the  climatic  conditions  are  unfavorable,  it  should  be  removed  to  a 
climate  where  an  oui>of-door  life  is  possible. 

In  the  medical  treatment  hydrochloric  acid  and  nux  vomica,  combined 
with  essence  of  pepsin,  in  doses  suited  to  the  age  of  the  infant  or  child,  are 
of  value.  It  may  also  be  necessary  to  wash  out  the  stomach  at  intervals 
and  to  give  as  a  laxative  occasional  doses  of  calomel  or  milk  of  magnesia. 
If  rickets,  syphilis  or  tuberculosis  be  present  they  should  receive  proper 
treatment. 

ULCER  OF  THE  STOMACH 

This  is  very  rare  in  childhood  and  even  more  so  in  infancy.  The  diag- 
nosis is  most  frequently  made  on  the  post-mortem  table,  the  child  having 
died  from  some  intercurrent  disease.  From  these  autopsy  findings  it  is 
evident  that  the  disease  is  not  commonly  characterized  by  a  symptomatology 
sufficiently  definite  to  make  the  diagnosis  plain.  When  these  ulcers  occur, 
as  they  sometimes  do  in  connection  with  acute  gastritis,  we  may  have  marked 
gastric  irritation  with  nausea  and  vomiting;  when  there  is  a  bloody  vomitus, 
associated  with  tarry  stools,  the  diagnosis  is  commonly  simple  enough. 
Rotch  and  others  have  recorded  cases  of  simple  perforating  ulcers,  but  these 
cases  are  extremely  rare.     Tuberculous  gastric  ulcers  are  also  seldom  seen. 

Treatment. — In  severe  cases  rectal  feeding  may  be  necessary  and  opium 
may  be  required  for  the  relief  of  pain,  but  for  the  most  part  the  treatment 
consists  in  a  preliminary  rest  for  the  stomach,  followed  by  a  carefully 
regulated  diet,  such  as  is  necessary  in  acute  gastritis.    The  use  of  alkalies. 


ACUTE  GASTRODUODENITIS  165 

such  as  lime  water  and  sodium  bicarbonate,  and  stomach  sedatives,  such  as 
bismuth,  are  of  value  in  relieving  the  symptoms.  If  perforation  occurs 
laparotomy  is  to  be  resorted  to  at  once. 

ACUTE  GASTRODUODENITIS 

( Catarrhal  Jaundice ) 

Catarrhal  jaundice  occurs  usually  between  the  second  and  the  fifth  year, 
being  almost  unknown  in  infancy  and  uncommon  after  the  fifth  year.  It 
is  probable  that  all  cases  are  due  to  some  infection,  which  produces  more 
or  less  duodenal  catarrh  with  an  accompanying  catarrh  of  the  common  bile 
duct,  resulting  in  its  obstruction.  The  bacteriology  of  this  condition  is  not 
known,  and  at  the  present  time  it  seems  improbable  that  all  cases  are  due 
to  the  same  bacterial  infection.  It  is  much  more  probable  that  the  disease 
may  be  produced  by  a  number  of  infections,  prominent  among  which  is  in- 
fluenza. The  writer  on  a  number  of  occasions  has  seen  two  cases  in  the 
same  family  of  children,  where  there  was  a  house  epidemic  of  influenza. 

Symptomatology. — The  early  symptoms  are  those  of  mild  gastric  indi- 
gestion, nausea,  vomiting,  gastric  discomfort,  fever  from  100°  to  103°  F., 
more  or  less  headache,  irritability,  nervousness,  mental  depression  and  gen- 
eral discomfort.  These  symptoms  continue  for  three  or  four  days  and  then 
jaundice  appears  and  the  diagnosis  is  made.  The  skin  and  conjunctiva 
assume  a  yellowish  hue  which  gradually  deepens  to  a  saffron  tint.  The 
child  is  usually  constipated,  the  stools  are  white  or  clay  colored  and  have 
a  bad  odor.  The  urine  contains  bile  and  is  of  a  yellowish-brown  color. 
There  are  pain  and  tenderness  over  the  duodenum,  the  tongue  is  heavily 
coated,  there  is  much  thirst  and  little  appetite,  and  occasionally  there  is 
an  uncomfortable  itching  of  the  skin,  but  this  latter  symptom  is  not  so 
common  as  in  the  forms  of  chronic  jaundice  seen  in  the  adult.  The  liver 
is  almost  always  enlarged  and  remains  so  for  some  days  after  the  jaundice 
has  disappeared.    The  spleen  may  be  palpated  in  most  cases. 

Course. — The  disease  lasts  from  two  to  three  weeks,  and  the  symptoms 
are  so  uniform  and  the  course  so  definite  that  it  gives  one  the  impression 
of  a  self-limited  acute  infection.  In  the  ordinary  course  of  the  disease  the 
gastric  symptoms  subside  within  the  first  week,  the  temperature  becomes 
normal,  the  appetite  returns,  and  the  general  discomfort  disappears,  but  the 
jaundice,  with  the  clay-colored  stools  and  bile-colored  urine,  continues  to 
the  end  of  the  third  week,  when  convalescence  is  usually  established,  but 
it  may  be  delayed  by  errors  in  diet. 

Diagnosis. — In  early  infancy  catarrhal  jaundice  does  not  occur.  The 
differential  diagnosis  from  other  conditions  producing  a  sallow  skin  is  made 
by  the  yellowness  of  the  conjunctiva  and  by  the  bile  in  the  urine. 

Treatment. — Preliminary  to  the  onset  of  the  jaundice,  before  the  diag- 
nosis is  made,  the  child  is  treated  for  ordinary  gastric  indigestion.  With 
the  onset  of  the  jaundice  calomel  is' to  be  given,  followed  by  Rochelle  salts, 
and  throughout  the  course  of  the  disease  the  bowels  are  to  be  irrigated  every 


166  DISEASES  OF   THE   STOMACH 

day  or  every  second  day,  and  phosphate  of  soda  is  to  he  given  in  sufficient 
quantities  to  insure  slight  laxative  action.  The  diet  during  the  acute  stages 
of  the  disease  should  be  of  skimmed  milk,  buttermilk,  bread,  cereals,  broth 
and  a  little  orange  juice.  Fats  are  to  be  especially  avoided  and  meats  are 
to  be  given  sparingly,  since  the  bile,  as  the  author  ^  many  years  ago  dem- 
onstrated, is  necessary  for  the  ready  digestion  and  assimilation  of  both  fat 
and  protein.  The  cereals  are  very  weU. borne,  especially  if  a  diastase  be 
given  with  the  meals. 

CONGENITAL  HYPERTROPHY  OF  THE  PYLORUS 

This  condition  has  attracted  considerable  attention  in  recent  years,  and 
there  can  be  no  doubt  but  that  the  clinical  syndrome  embraced  under  this 
heading  is  not  so  infrequent  as  formerly  supposed,  but  there  is  still  much 
difference  of  opinion  as  to  the  actual  lesions  which  produce  it. 

Etiology  and  Pathology.— It  is  generally  conceded  that  there  is  a  con- 
genital condition  in  which  the  pylorus  is  thickened  and  its  lumen  so  greatly 


Fio.  25. — Congenital  Stenosis  of  the  Pylorus.    (Bevan.) 

reduced,  that  it  acts  as  a  serious  obstruction  to  the  transfer  of  the  food  con- 
tents of  the  stomach  to  the  small  intestine.  The  pylorus  may  form  a  small 
tumor  which  can  be  felt  and  occasionally  seen  through  the  abdominal  wall. 
The  lumen  at  the  point  of  greatest  hypertrophy  of  the  sphincter  may  be 
so  small  as  to  admit  only  a  fine  probe.  It  is  also  conceded  that  this  mus- 
cular hypertrophy,  which  involves  the  pyloric  end  of  the  stomach  as  well 
as  the  pylorus  itself,  is  associated  with  spasm,  which  greatly  aggravates  the 
constriction.  Thompson  suggested  that  the  pyloric  spasm  might  be  the 
initial  lesion  occurring  soon  after  birth,  being  produced  by  the  swallowing 
of  liquor  amnii,  and  that  this  fluid  and  other  irritating  substances  produced 
by  the  fermentation  of  food  and  mucus  might  continue  the  exaggerated 
^Journal  of  Physiology,  1891. 


CON^GEmTAL  HYrERTROPHY   OF   THE   PYLORUS       167 


action  of  the  pyloric  sphincter  and  muscular  coats  of  the  stomach,  and  thus 
produce  a  secondary  hypertrophy  of  these  muscles,  which  would  increase 
the  constriction  and  finally  result  in 
more  or  less  marked  hypertrophy  and 
permanent  constriction.  Whatever 
may  he  the  relative  importance  of  the 
congenital  hypertrophy  and  the  py- 
loric spasm  in  the  etiology  of  this 
condition,  it  is  conceded  that  both 
these  factors  exist,  and  I  am  inclined 
to  believe  with  Koplik  that  there  are 
two  distinct  groups  of  cases:  one  in 
which  there  is  a  spasm  of  the  pylorus 
and  pyloric  end  of  the  stomach,  with 
little  or  no  hypertrophy,  and  the 
other  in  which  the  essential  lesion  is 
hypertrophy  of  the  pylorus,  and  that 
the  symptom  group  in  these  cases  is 
aggravated  by  an  associated  pyloric 
spasm. 

Symptomatology.— The  first  and 
all-important  symptom  in  these  cases 
is  vomiting.  In  the  great  majority 
of  cases  it  begins  in  the  third  or 
fourth  week,  but  in  rare  instances  it 
may  begin  a  few  days  after  birth  or 
may  be  delayed  to  the  seventh  or  the 
eighth  week.  In  the  beginning  the 
vomiting  may  occur  only  once  or 
twice  in  the  twenty-four  hours,  but  gradually  increases  in  frequency  and 
force,  until,  within  the  course  of  a  week  or  ten  days,  nearly  all  of 
the  food  is  vomited  directly  after  taking.  In  the  rapid  development 
of  this  symptom  there  can  be  little  doubt  but  that  pyloric  spasm 
plays  an  important  role,  and  even  during  the  height  of  the  disease 
there  is  at  times  a  strange  intermittency  in  the  force  and  frequency  of  the 
vomiting.  Instead  of  occurring  with  great  force  directly  after  the  taking 
of  food  this  character  of  vomiting  may  be  superseded  for  a  few  hours  by 
comparative  tolerance  on  the  part  of  the  stomach  for  food,  and  the  vomiting 
may  occur  only  after  the  food  has  remained  in  the  stomach  for  hours,  and 
again,  directly  after  vomiting,  food  may  be  taken  and  retained  until  after  the 
next  feeding,  when  the  whole  contents  of  the  stomach  are  ejected  with  con- 
siderable force.  The  infant  ceases  to  gain  in  weight  and  then  commences 
to  lose  and,  as  the  chronic  vomiting  continues,  becomes  emaciated  and 
malnoiirished  to  the  last  degree.  Constipation  is  always  present;  it  may 
exist  with  a  discharge  from  the  bowel  several  times  during  the  day  of  small 
liquid  stools,  consisting  largely  of  mucus  and  bile.    A  close  study  of  these 


Fig.  26. 


-Congenital   Stenosis 
Pylorus. 


Longitudinal  section,  through  tumor  mass. 
(Bevan.) 


168  DISEASES  OF  THE   STOMACH 

discharges  will  show  that  comparatively  little  or  no  food  has  passed  from 
the  stomach  into  the  intestine.  After  taking  food  the  child  suffers  more  or 
less  gastric  discomfort,  and  if  the  disease  continues  for  a  long  time,  there  is 
more  or  less  marked  dilatation  of  the  stomach.  It  is  an  afebrile  condition. 
All  of  the  above  symptoms  may  be  produced  by  pyloric  spasm  even 
thougii  there  be  little  or  no  liypertrophy  of  the  pylorus,  but  when  marked 
hypertrophy  of  the  pylorus  exists  the  above  symptom  group  is  exaggerated, 
and  there  are  in  addition  two  physical  signs  of  great  diagnostic  importance. 
One  of  these,  tlie  most  characteristic  of  all,  is  a  small,  movable  nodule 
which  may  be  felt  on  deep  pressure  in  the  region  of  the  pylorus,  between 
the  margin  of  the  liver  and  the  umbilicus.  This  tumor,  which  should  al- 
ways be  searched  for,  is  the  pathognomonic  sign  of  hypertrophy  of  the 
pylorus,  and  in  cases  where  it  cannot  be  felt  there  must  remain  some  doubt 
as  to  the  presence  of  this  condition.  The  other  sign  which  is  commonly 
noted  in  these  eases  is  the  peristaltic  movements  of  the  stomach,  which  can 
be  seen  through  the  distended  abdominal  wall.  Valuable  information  as  to 
the  patulency  of  the  pylorus  may  be  obtained  by  giving  the  infant  a  large 
dose  of  subnitrate  of  bismuth,  and  one  hour  later  determining  by  an  X-ray 
picture  whether  or  not  the  bismuth  has  passed  the  pylorus. 

Diagnosis. — According  to  Koplik,  the  diagnosis  of  pyloric  spasm  without 
hypertrophy  of  the  pylorus  is  made  largely  by  the  absence  of  the  pyloric 
tumor,  and  the  presence  of  the  stomach  peristalsis  and  a  projectile  vomiting 
which  empties  the  stomach,  and  the  presence  in  the  stools  of  a  certain 
amount  of  fecal  matter,  which  indicates  that  considerable  food  may  have 
passed  from  the  stomach  into  the  intestine.  The  diagnosis  of  hypertrophy 
is  made  by  the  presence  of  all  the  symptoms  of  pyloric  spasm,  plus  the 
pyloric  tumor,  the  stomach  peristalsis,. the  almost  complete  absence  of  fecal 
matter  in  the  stools  and  retentive  vomiting  in  contradistinction  to  full 
vomiting.  Morse  says,  the  most  important  points  in  favor  of  spasm  in 
doubtful  cases  are  the  absence  of  a  palpable  tumor,  or,  if  a  tumor  is  present, 
its  cord-like  feel,  the  presence  of  intermittent  contraction  and  relaxation 
of  the  tumor,  and  rapid  improvement  under  medical  treatment  and  regula- 
tion of  the  diet.  He  believes  that  a  cord-like  tumor  may  sometimes  be  felt 
when  no  hypertrophic  stenosis  exists,  and  that  in  some  cases  of  hypertrophic 
stenosis  no  tumor  can  be  felt.  He  also  says  that  if  the  baby  is  breast-fed  the 
chances  are  greatly  in  favor  of  hypertrophic  stenosis,  and  if  it  be  artificially 
fed,  the  chances  are  even. 

The  only  common  disease  with  which  hypertrophy  of  the  pylorus  may  be 
confused  is  chronic  gastric  catarrh.  This  condition  may  be  differentiated 
by  the  fact  that  in  chronic  gastric  catarrh  there  is  apparent  cause  for  the 
onset  of  the  vomiting  and  also  for  its  continuation,  and  the  vomiting  in 
this  condition  subsides  when  the  stomach  is  rested  and  a  proper  diet  is 
given,  so  that  there  is  little  reason  for  mistakes  in  diagnosis  after  the  con- 
ditions have  been  studied  for  a  few  days. 

There  are  other  very  rare  conditions,  such  as  stricture  of  the  duodenum, 
either  congenital  or  resulting  from  cicatricial  contractions  following  ulcers. 


CONGENITAL  HYPERTROPHY   OF    THE   PYLORUS       169 


and  scars  of  the  pylorus,  which  are  so  infrequent  that  they  scarcely  deserve 
consideration.  In  the  event,  however,  of  the  existence  of  these  conditions 
their  treatment  would  be  the  same  as  that  of  congenital  hypertrophy  of  the 
pylorus. 

Prognosis — The  prognosis  of  pyloric  spasm  uncomplicated  by  hyper- 
trophic    stenosis     is 

favorable.  But  the 
prognosis  of  pyloric 
stenosis,  which  is  al- 
ways complicated  by 
pyloric  spasm,  is 
grave,  since  many  of 
these  cases  are  not 
relieved  by  dietetic 
treatment.  The  sur- 
gical treatment,  how- 
ever, is  successful  in 
about  50  per  cent, 
of  these  cases,  and 
the  after  results  are, 
as  a  rule,  good,  al- 
though Koplik  notes 
that  quite  a  percent- 
age of  the  cases 
which  survive  the 
operation  ultimately 
develop  grave  forms 
of  malnutrition.  The 
fact  remains,  how- 
ever, that  in  a  large 
percentage  of  these 
otherwise  hopeless 
cases,  surgery  sa\Tes 
the  life  of  the  child 
and  gives  it  a  fair 
chance  to  be  restored 
to  a  satisfactory  con- 
dition of  health.  Of 
the  five  operative 
cases  that  have  come  within  my  personal  knowledge,  four  recovered  and  are 
now  apparently  well. 

Treatment. — In  view  of  the  fact  that  a  large  percentage  of  these  cases 
may  be  cured  without  resorting  to  the  knife,  it  is  advisable  that  every 
case  should  have  careful  dietetic  and  medical  treatment  until  it  has  been 
fully  demonstrated  that  such  treatment  is  of  no  avail.  Since  all  of  these 
cases  occur  so  early  in  life,  the  great  majority  of  them  are  developed  on 


Fig.  27. — Pyloric  Stenosis.  (Radiography 
Taken  three-quarters  of  an  hour  after  the  administration  of 
bismuth  paste.      Not«  fine  stream  of  paste  escaping   from 
the  pylorus.  Patient  age  thirteen  weeks.  Complete  recovery 
without  operation.     (Max  Dreyfoos.) 


170  DISEASES  OF  THE   STOMACH 

breast  feeding,  but,  whatever  may  be  the  food  of  the  infant,  with  the  onset 
of  the  symptoms  the  stomach  sbould  be  waslied  out  with  a  sodium  clilorid 
solution  (one  level  teaspoonful  to  a  pint  of  water),  and  throughout  the 
treatment,  especially  where  retentive  vomiting  is  present,  stomach  washing 
sliould  be  resorted  to,  from  time  to  time,  as  necessary.  After  the  preliminary 
washing  of  the  stomach  no  food  should  be  given  for  a  period  of  at  least 
twenty-four  hours,  but  during  the  latter  portion  of  this  time  small  quanti- 
ties of  salt  solution  may  be  given  by  the  mouth.  If  this  is  retained  two  or 
three  small  breast  feedings  may  be  given  within  the  next  twenty-four  hours. 
If  the  breast  milk  disagrees  and  the  vomiting  recurs,  the  stomach  should 
have  a  rest  and  the  breast  milk  of  another  wet  nurse  may  then  be  tried. 
Skimmed  breast  milk  will  sometimes  be  retained  when  ordinary  breast 
milk  will  not.  It  is  important  that  the  breast  milk  be  given  in  small  quanti- 
ties and  at  intervals  of  at  least  four  hours  during  the  first  three  or  four 
days  of  the  treatment ;  in  some  instances  the  gastric  irritation  and  pyloric 
spasm  may  be  relieved  by  giving  directly  before  each  nursing  a  few  tea- 
spoonfuls  of  equal  parts  of  water  and  lime  water.  During  this  period  of 
insufficient  nourishment  small  quantities  of  salt  solution  may  be  given  by  the 
mouth,  and  5  or  6  ounces  of  the  same  solution  may  be  thrown  high  up  into 
the  bowel  at  such  intervals  as  may  be  necessary  to  overcome  thirst  and  to 
supply  the  body  with  fluids.  If  breast  feeding  fails  entirely  a  radical 
change  in  the  food  may  be  resorted  to.  Whey  and  peptonized  fat-free  milk 
are  foods  which  may  serve  the  temporary  purpose  of  allaying  gastric  irrita- 
tion and  pyloric  spasm,  and  thus  pave  the  way  for  a  third  trial  of  breast 
milk.  If  success  follows  any  form  of  dietetic  treatment  one  should  be  most 
careful  not  to  change  the  diet  of  the  infant  until  the  condition  of  the  child's 
stomach  warrants,  and  the  nutrition  of  the  infant  demands  that  a  change 
should  be  made.  In  the  event,  however,  that  all  dietetic  measures  fail,  the 
patient  should  be  prepared  for  operative  treatment  by  hypodermoclysis  of 
physiological  salt  solution  and  turned  over  to  the  surgeon  for  operation. 
He  may  then  determine  the  nature  of  the  operation  to  be  performed  in  the 
individual  case.  Gastroenterostomy,  pyloroplasty  and  Loreta's  operation 
have  all  been  performed  with  success  in  these  cases ;  the  first  of  these  is  the 
favorite  at  the  present  time. 

CHRONIC  GASTRITIS 

(Chronic  Gastric  Catarrh) 

This  is  a  very  common  disorder,  especially  in  infants  and  young  chil- 
dren, and  is  usually  associated  with  diarrhea  and  chronic  intestinal  indiges- 
tion ;  this  subject  will  be  more  fully  treated  under  the  latter  heading. 

Etiology. — Chronic  gastric  catarrh  is  frequent  during  the  first  year  of 
life  and  is  usually  caused  by  taking  too  much  food  at  too  short  intervals; 
this  applies  especially  to  bottle-fed  babies.  If  for  example  an  infant  three 
months  of  age,  that  should  l)e  taking  4  ounces  of  food  every  three  hours,  is 
given  6  or  7  ounces  or  "all  it  will  take,"  especially  at  irregular  intervals, 


CHRONIC    GASTEITIS  171 

trouble  will  surely  follow.  The  overworked  stomach  becomes  distended,  its 
motor  power  diminished,  its  mucous  membrane  diseased,  tlie  gastric  secre- 
tions impaired,  but  appetite  and  thirst  may  still  continue,  so  that  the  in- 
fant's stomach  is  never  empty,  and  fermentation  and  gastric  irritation  re- 
sult; such  is  the  common  etiology  of  this  disease  in  young  infants.  Bad 
hygiene,  impure  air,  lack  of  sunlight,  filthy  surroundings  and  constitutional 
diseases,  such  as  tuberculosis,  syphilis  and  rickets,  which  produce  malnutri- 
tion and  anemia,  are  important  predisposing  causes.  Eecurring  attacks  of 
acute  gastritis  may  be  a  part  of  the  early  history  of  this  disease.  In  older 
children  also,  the  cause  is  too  much  food  and  improper  food  at  irregular 
intervals. 

Pathology. — The  stomach  is  dilated  and  the  mucous  membrane  is  cov- 
ered with  a  tough  tenacious  mucus.  The  changes  are  somewhat  similar  to 
those  found  in  acute  gastric  catarrh,  except  that  the  swelling  and  congestion 
of  the  mucous  membranes  are  not  so  marked,  and  petechial  hemorrhages 
and  marked  injection  of  blood  vessels  do  not  exist.  The  mucous 
membrane  is  infiltrated  with  round  cells,  is  thickened,  and  there  are  ero- 
sion and  degeneration  of  the  epithelial  cells,  especially  in  and  around  the 
gastric  tubules. 

Symptomatology. — Vomiting  is  the  characteristic  symptom.  It  may  oc- 
cur every  day,  or  every  other  day,  or  at  longer  or  shorter  intervals,  depend- 
ing upon  the  severity  of  the  case  and  the  character  of  the  food  administered. 
In  older  children  vomiting  occurs  more  frequently  in  the  early  morning 
than  at  any  other  time,  but  in  infants  it  may  occur  at  any  time  when  the 
stomach  is  overfull.  The  vomited  matter  consists  of  undigested  food  and 
of  glairy,  tenacious  mucus  which  is  acid  from  the  presence  of  the  fermenta- 
tion acids,  acetic,  butyric  and  lactic ;  hydrochloric  acid  is  almost  never  pres- 
ent. In  infants  gastric  indigestion  and  diarrhea  are  common ;  children  over 
two  years  of  age  are,  as  a  rule,  constipated.  For  a  long  time  the  appetite 
may  remain  good  and  is  unfortunately  much  larger  than  the  digestive  ca- 
pacity. The  child  is  nervous,  irritable,  sleeps  badly,  frets,  whines  and  de- 
mands more  or  less  constant  attention.  It  may  cry  for  food  and  take  with 
avidity  more  than  the  normal  quantity,  and  yet  suffer  from  gastric  pain  and 
discomfort  soon  after.  It  fails  to  gain  in  weight  and  as  the  disease  pro- 
gresses there  are  loss  of  weight,  dry  skin  and  anemia.  The  face  becomes 
thin  and  old-looking,  the  belly  large  and  tympanitic  and  the  legs  thin ;  the 
appetite  is  gradually  lost,  and  emaciation  and  malnutrition  increase  until 
death  occurs  from  exhaustion.  This  extreme  picture,  however,  is  fortunately 
not  very  common  except  in  young  infants.  In  older  infants  and  children 
all  of  the  symptoms  are  much  less  severe,  the  vomiting  is  not  so  frequent 
and  the  disease  yields  much  more  readily  to  treatment,  so  that,  as  a  rule, 
the  severe  symptoms  leading  to  extreme  emaciation  and  profound  malnutri- 
tion are  uncommon  unless  the  intestinal  canal  be  involved. 

Diagnosis. — The  diagnosis  is  not  difficult,  the  chronic  vomiting,  gastric 
discomfort,  epigastric  tenderness  associated  with  malnutrition  and  anemia, 
occurring  as  an  afebrile  condition  in  an  infant,  cannot  be  mistaken  for  any 


172  DISEASES  OF  THE   STOMACH 

other  disease  except  congenital  pyloric  spasm.  ( See '  Congenital  Hyper- 
trophy of  the  Pylorus.) 

Prognosis.— The  prognosis  largely  depends  upon  the  age  of  the  child 
and  the  stage  of  the  disease  when  proper  treatment  is  instituted.  If  the 
diagnosis  is  made  early  the  prognosis  is  good  even  in  young  infants,  but 
otherwise  at  this  age  it  is  very  doubtful.  In  children  over  three  years  of 
age  it  is  good,  but  it  may  require  months  or  years  in  a  well-established  case 
to  completely  overcome  all  evidences  of  the  disease. 

Treatment.— One  of  the  first  indications  is  to  cleanse  the  stomach  and 
keep  it  as  clean  as  possible.  In  infants  under  one  year  of  age  this  may 
very  readily  be  done  by  washing  out  the  stomach  once  a  day  with  a  weak 
bicarbonate  of  soda  or  sodium  chlorid  solution,  one-half  drachm  to  the 
pint ;  this  warm  alkaline  solution  should  be  used  about  three  hours  after  a 
feeding.  In  older  children  the  stomach  tube  cannot  so  readily  be  used  and 
in  these  cases  the  cleansing  may  be  done  by  milk  of  magnesia,  Eochelle 
salts  or  sodium  phosphate,  taken  before  meals  once  or  twice  a  day  in  suffi- 
cient quantities  to  relieve  constipation.  If  the  children  are  old  enough  it  is 
also  advisable  to  have  them  sip  hot  water  in  which  has  been  dissolved  some 
bicarbonate  of  soda ;  this  should  be  done  one  hour  before  meals.  The  careful 
selection  of  a  proper  diet  is  very  difficult  in  these  cases,  and  yet  upon  it 
depends  their  successful  treatment.  On  general  principles  one  may  say  it 
is  advisable  at  all  ages  to  avoid  fats  and  to  give  small  quantities  of  food  at 
long  intervals,  the  object  being  to  have  the  stomach  empty  itself  before  it  is 
required  to  undertake  the  digestion  of  another  meal.  The  diet  must,  of 
course,  suit  the  age  and  digestive  capacity  of  the  individual  infant.  If  the 
food  happens  to  be  breast  milk,  then  something  must  be  radically  wrong 
with  that  particular  breast  milk,  or  it  must  have  been  fed  as  to  interval  and 
quantity  most  unwisely.  In  such  instances  it  is  advisable,  if  the  symptoms 
do  not  yield  readily,  to  change  to  another  wet  nurse,  and  if  this  procedure 
fails  the  infant  should  be  put  upon  modified  cow's  milk.  Infants  that  have 
been  taking  cow's  milk  or  other  foods  when  the  gastric  catarrh  developed 
are  to  have  their  milk  formulas  carefully  regulated  with  reference  to  their 
digestive  capacity.  The  foods  that  usually  agree  with  these  infants,  fat -free 
milk,  peptonized  milk  and  buttermilk,  may  be  tried  in  the  order  named. 
The  fat-free  milk  and  the  peptonized  milk  should  be  diluted  with  dextrin- 
ized  gruels,  and,  as  the  infant  improves,  dextrinized  gruels  may  be  dimin- 
ished and  the  quantity  of  skimmed  milk  or  peptonized  milk  in  the  mix- 
ture gradually  increased.  The  buttermilk  mixture  may  be  prepared  by 
adding  to  a  pint  of  buttermilk  a  tablespoonful  of  wheat  flour  and  two 
tablespoonf uls  of  cane  sugar,  and  boiling  thirty  minutes.  This  mixture  may 
be  given  every  four  hours  to  infants  between  the  ages  of  six  and  ten  months, 
and  the  quantity  should  be  one  ounce  less  than  they  are  months  old.  This 
is  an  excellent  food  and  agrees  with  many  eases.  Meat  juice,  in  suitable 
quantities,  diluted  with  a  little  water,  may  be  added  to  the  infant's  diet 
after  it  has  been  demonstrated  that  any  one  of  the  above-named  milk  prep- 
arations is  agreeing  with  it.     One  of  the  proprietary  milk  foods,  such  as 


ETIOLOGY  173 

Nestle's,  is  often  of  value  in  the  treatment  of  these  cases.  If  the  Nestle's 
food  is  used,  5  or  10  drops  of  a  liquid  diastase  should  be  added  to  each  feed- 
ing and  later  small  quantities  of  fat-free  or  peptonized  milk  are  to  be 
added,  and  as  these  foods  are  added  the  proportion  of  the  Nestle's  food  is 
diminished,  so  that  in  time  one  of  the  milk  preparations  gradually  replaces 
the  proprietary  food.  In  older  children,  as  they  commence  their  convales- 
cence, meat,  eggs,  cereals,  bread  and  later  orange  juice  may  be  added. 

The  hygienic  treatment  of  these  cases  is  very  important;  it  may  be 
necessary  to  send  them  to  a  cool  climate  during  the  hot  summer  months 
and  to  a  warm  climate  during  the  cold  and  disagreeable  months  of  winter. 
The  object  of  these  changes  is  to  put  the  infant  under  such  climatic  con- 
ditions as  will  give  it  plenty  of  sunlight  and  fresh  air  without  subjecting  it 
to  the  depressing  effects  of  the  heat  of  summer  or  the  chilling  effects  of 
damp,  cold  winters.  If  it  be  necessary  to  keep  it  out  of  doors  in  cool 
weather  it  must,  because  of  its  diminished  vitality,  be  dressed  warmly; 
above  all,  the  feet  and  legs  should  be  kept  warm  by  hot  water  bottles  and 
proper  clothing.  In  young  infants  inunctions  of  lanolin  once  a  day  serve 
the  purposes  of  furnishing  a  light  form  of  exercise,  increasing  the  periph- 
eral circulation  and  causing  the  absorption  of  small  quantities  of  easily 
assimilable  fat.  In  older  children  mild  exercise  in  the  open  air  is  ad- 
visable. Hydrochloric  acid  and  pepsin  given  after  meals  are  of  value  in 
many  of  these  cases.  Pancreatin  and  the  thick  malt  preparations  may  be 
used  to  promote  the  digestion  and  the  absorption  of  carbohydrate  foods.  In 
older  children  nux  vomica,  in  small  doses  before  meals,  serves  to  stimulate 
the  digestive  capacity.  Holt  recommends  the  use  of  salicylate  of  soda  in 
1-  or  2-gr.  doses  to  control  gastric  fermentation. 


CHAPTER  XIX 

ETIOLOGY     AND     PREVENTIVE     TREATMENT     OF     THE     INTESTINAL 
DISORDERS    OF    INFANCY 

ETIOLOGY 

These  disorders  include  intestinal  indigestion,  intestinal  intoxication 
and  intestinal  catarrh.  To  avoid  repetition  the  etiology  and  preventive 
treatment  of  these  conditions  may  be  considered  under  the  same  heading, 
since  they  very  commonly  occur  in  the  sequence  given  above.  The  indi- 
gestion may  be  the  initial  disturbance  which  predisposes  to  the  intoxication, 
and  the  latter  very  commonly  results  in  intestinal  catarrh.  These  intestinal 
disorders  are  not  sharply  defined  from  each  other  either  in  their  etiology  or 
treatment.  On  the  other  hand,  they  are  to  a  large  extent  the  result  of  the 
same  etiological  processes  and  commonly  but  different  steps  in  the  same 
pathological  process,  and  their  treatment  is  very  much  along  similar  lines. 
Kerley  has  justly  laid  great  stress  upon  the  importance  of  intestinal  indi- 


174  INTESTINAL   DISORDERS    OF    INFANCY 

gestion  in  predisposing  infants  to  more  serious  gastrointestinal  diseases, 
and  Ocrnian  writers,  especially  Czerny,  Keller  and  Finkektein,  have  dem- 
onstrated that  the  most  serious  gastrointestinal  disorders  follow  in  the  wake 
of  indigestion  produced  by  overfeeding.  The  relationship  which  exists  be- 
tween intestinal  indigestion,  intoxication  and  catarrh  is  forcibly  brought 
to  our  minds  by  the  increased  death  rate  of  infants  during  the  hot  summer 
months.  Infants  who  have  suffered  from  frequent  attacks  of  gastrointes- 
tinal indigestion  throughout  the  year  and  who  have,  therefore,  feeble  di- 
gestive capacities  and  feeble  powers  of  resistance,  are  very  prone  to  diar- 
rheal diseases.  Infants  of  this  class  are  often  wrongly  Judged  to  be  in- 
capable of  digesting  cow's  milk  and  are,  therefore,  injudiciously  placed  upon 
more  easily  digested  foods,  such  as  condensed  milk,  proprietary  foods  and 
other  ill-balanced  food  formulas,  and  as  a  result  of  such  feeding  they  be- 
come rachitic  and  otherwise  malnourished.  With  these  malnutritions  super- 
imposed upon  a  feeble  digestive  capacity  and  feeble  powers  of  intestinal 
resistance,  they  are  ill  prepared  to  stand  the  dangers  from  more  serious 
gastrointestinal  diseases  which  beset  them  during  the  hot  summer  months. 
The  great  death  rate  among  weaklings  of  this  class  perhaps  accounts  for  the 
rapid  increase  of  infantile  mortality  from  diarrheal  diseases  in  our  large 
cities  during  the  early  summer  months. 

Among  the  predisposing  causes  of  the  intestinal  disorders  of  infancy 
are  rickets,  syphilis,  tuberculosis,  anemia,  neurotic  inheritance,  prolonged 
heat  of  summer  and  bad  hygienic  conditions,  including  impure  air  and  lack 
of  sunlight.  Any  or  all  of  these  factors  may,  by  lowering  the  resistance  of 
the  infant,  reduce  its  physiological  digestive  capacity,  diminish  its  tolerance 
for  any  one  of  the  food  ingredients  of  milk  and  predispose  it  to  attacks  of 
indigestion,  intoxication  and  intestinal  catarrh.  A  feeble,  malnourished 
infant  that  has  been  getting  on  fairly  well  on  a  carefully  modified  milk 
mixture  may,  when  the  heat  of  summer  lowers  its  digestive  capacity,  suffer 
an  acute  intestinal  disturbance  caused  by  the  self-same  food  upon  which 
it  has  been  previously  thriving.  In  normal  infants  a  much  more  potent 
exciting  cause,  such  as  overfeeding  or  contaminated  milk,  is  commonly  nec- 
essary to  produce  intestinal  disorders. 

Intestinal  disturbances  are  much  less  common  and  much  less  severe  in 
breast-fed  than  in  artificially  fed  infants.  During  the  first  week  of  life 
indigestion  is  common,  resulting  from  the  physiological  incompetency  of  the 
gastrointestinal  canal  and  abnormalities  in  the  mother's  milk ;  it,  as  a  rule, 
quickly  disappears  as  the  intestinal  canal  adjusts  itself  to  its  physiological 
duties  and  the  milk  supply  of  the  mother  becomes  more  normal  and  stable 
in  its  composition.  Later  on  in  the  life  of  the  infant,  indigestion  and  diar- 
rhea may  result  from  variations  in  the  fat  and  protein  constituents  of  the 
milk,  produced  by  menstruation,  nervous  shock,  dissipation,  imprudence  in 
diet,  ill  health  and  the  failure  to  observe  proper  hygienic  rules  on  the  part 
of  the  mother.  These  defects  are  usually  transitory  and  can  be  corrected 
by  regulating  the  life  and  diet  of  the  mother ;  if  not,  there  is  some  radical 
defect  in  the  milk  and  another  wet  nurse  should  be  secured.     There  is. 


ETIOLOGY  176 

however,  no  more  common  error  in  infant  feeding  nor  one  that  is  responsible 
for  greater  loss  of  life  than  that  of  taking  infants  from  the  breast  for  slight 
and  remediable  causes. 

Overfeeding  is  the  most  important  cause  of  indigestion,  and  the  indi- 
gestion thus  produced  may  lead  to  more  serious  intestinal  disorders;  this 
fact  has  been  most  graphically  pointed  out  by  Czerny  and  Keller.  Very 
pronounced  and  very  persistent  gastrointestinal  indigestion  may  result  even 
from  normal  breast  milk  given  in  too  large  quantities  and  at  too  short  in- 
tervals; but  it  must  be  said  that  the  infant  shows  a  remarkable  tolerance 
for  human  milk;  it  is  more  difficult  to  make  it  ill  by  overfeeding  with 
breast  milk  than  with  any  other  food.  The  breast  milk,  however,  taken 
in  twenty-four  hours  should  not,  in  caloric  value,  much  exceed  the  demands 
of  the  infant,  and  it  should  not  be  given  at  such  short  intervals  that  the 
stomach  will  not  have  time  to  almost  or  quite  empty  itself  before  another 
supply  enters  it.  In  America  the  dangers  from  overfeeding  with  breast 
milk  are  not  very  great,  since  American  mothers,  as  a  rule,  furnish  insuffi- 
cient rather  than  a  superabundant  supply  of  milk.  This  form  of  indiges- 
tion, if  recognized,  is  easily  corrected  in  the  breast-fed  infant  by  allowing 
smaller  quantities  of  breast  milk  at  longer  intervals  until  convalescence  is 
established  and  then  allowing  it  to  nurse  at  regular  four-hour  intervals. 

In  artificially  fed  infants  overfeeding,  as  a  cause  of  intestinal  disorders, 
is  much  more  important  and  much  more  serious  in  its  consequences.  It  may 
produce  violent  and  prolonged  gastrointestinal  disturbances,  which  may  be 
complicated  by  intestinal  infection  and  end  in  enterocolitis.  Czerny, 
Keller,  Finkelstein  and  others  insist  with  reason  that,  apart  from  a  com- 
plicating infection  and  intestinal  catarrh,  overfeeding  may  produce  an  in- 
jury to  the  metabolic  processes  of  the  infant,  manifesting  itself  at  first 
in  a  severe  indigestion  and  later  in  fever  and  profound  nervous  and  other 
constitutional  symptoms  so  severe  that  it  may  require  weeks  of  careful  under- 
feeding to  restore  the  infant  to  a  normal  condition.  In  most  of  these  cases 
it  will  be  found  that  the  infant  has  suffered  a  special  "food  injury"  which 
very  markedly  diminishes  its  tolerance  for  either  the  fat,  the  sugar,  the  salts 
or  the  proteins  of  milk,  and,  in  the  subsequent  feedings,  it  will  be  necessary 
for  a  time  to  greatly  reduce  the  particular  ingredient  of  the  milk  for  which 
the  infant's  tolerance  has  been  reduced;  this  is  commonly,  early  in  the 
disease,  the  fat  (cream),  and  later,  the  sugar  or  whey  salts.  Overfeeding  is 
a  much  more  potent  cause  of  indigestion  if  it  be  associated  with  too  frequent 
feedings ;  the  digestive  organs  of  the  artificially  fed  infant  must  have  regu- 
lar periods  of  rest,  and  this  means  feeding  at  long  and  at  regular  intervals. 
Too  rapid  increase  in  the  strength  of  the  food  formula  and  improper  and 
unwholesome  food  are  important  causes  of  indigestion.  In  the  artificially 
fed  infant,  whatever  may  be  the  cause,  the  results  are  less  serious  if  it  can 
be  fed  during  its  convalescence  on  breast  milk.  These  dietetic  errors  may 
produce  acute  intestinal  disorders  even  in  normal  infants,  but  they  act  much 
more  rapidly  and  the  symptom  complex  which  they  produce  is  much  more 
severe  in  feeble,  malnourished  children. 
13 


176  INTESTINAL   DISORDERS    OF    INFANCY 

The  swallowing  of  mucus,  which  occurs  in  catarrhal  conditions  of  the 
respiratory  tract  in  infants,  is  a  very  coninion  cause  of  gastric  and  intes- 
tinal disturbances.  Unwise  cathartic  medication  or  drugs,  especially  those 
belonging  to  the  so-called  expectorant  class,  such  as  ipecac,  squills  and 
ammonia,  so  commonly  given  to  very  young  infants  suffering  from  catarrhal 
conditions  of  the  respiratory  passages,  may,  if  not  given  with  much  dis- 
cretion, produce  acute  intestinal  disorders.  Dentition  and  exposure  to  wet 
and  cold  may,  especially  in  feeble  infants,  act  as  exciting  factors  of  indi- 
gestion and  diarrhea. 

In  older  children  much  more  potent  factors  than  those  above  named  are 
commonly  required  to  produce  attacks  of  intestinal  disturbance.  They  are 
not  so  easily  upset  by  the  quantity  of  food  taken  or  by  eating  at  irregular 
times  provided  the  food  is  wholesome,  nor  are  they  so  easily  affected  by  the 
ordinary  bacterial  contamination  of  milk.  Indigestion  with  them  commonly 
results  from  rather  gross  errors  in  diet,  such  as  the  eating  of  green  fruit 
and  large  quantities  of  sweets  and  pastries. 

Acute  intestinal  toxemia  may  come  and  go  without  producing  acute  en- 
teritis, but  on  the  other  hand  practically  every  enteritis  is  preceded  or  ac- 
companied by  a  bacterial  infection  producing  an  intestinal  toxemia  and  sub- 
sequent catarrh.  This,  however,  does  not  imply  that  the  initial  or  most  im- 
portant etiological  factors  of  every  case  of  enteritis  are  bacteria,  but  it  does 
imply  that  the  bacterial  factors  are  all-important  in  producing  the  patho- 
logical changes  which  underlie  and  prolong  these  diseases.  Acute  intestinal 
toxemias  are  caused  by  a  variety  of  microorganisms  which  produce,  by  their 
action  on  food  stuffs,  soluble  and  irritant  poisons.  Some  of  these  poisons 
irritate  the  intestinal  mucosa;  others  are  absorbed  and  exert  a  poisonous 
action  on  the  nerve  centers,  especially  the  anterior  horns  of  the  spinal  cord. 
In  some  instances  the  poisonous  bacterial  products  are  formed  in  such  quan- 
tities in  milk  and  other  food  before  they  are  taken  into  the  gastrointestinal 
canal,  that  a  violent  and  dangerous  intoxication  follows  directly  upon  taking 
such  contaminated  food.  These  cases  are  commonly  grouped  under  the 
term  "milk  or  food  poisoning,"  and  they  have  been  especially  elucidated  by 
the  researches  of  Vaughn,  who  has  succeeded  in  isolating  from  contaminated 
foods  soluble  poisons,  among  them  tyrotoxicon,  by  the  introduction  of 
which  into  the  gastrointestinal  canal  of  animals  he  was  able  to  produce  a 
symptom  group  similar  to  that  produced  by  food  poisoning.  In  other  in- 
stances— and  these  are  the  common  ones — ^the  milk  at  the  time  of  taking  is 
so  shghtly  contaminated  with  pathogenic  bacteria  that  it  simply  acts  by 
starting  a  pathogenic  fermentation  in  the  food  contents  of  the  intestinal 
canal  of  the  infant.  As  this  fermentation  proceeds,  irritant  and  soluble 
toxins  are  formed,  which  sooner  or  later  produce  more  or  less  severe  symp- 
toms of  intestinal  irritation  and  constitutional  poisoning.  It  is  also  prob- 
able that  certain  bacteria  which  are  commonly  present  in  the  intestinal 
canal  of  normal  infants  may,  as  a  result  of  overtaxing  the  digestive  organs 
with  too  much  food  or  improper  food,  become  pathogenic,  setting  up  ab- 
normal fermentations  which  produce  irritant  and  constitutional  poisons. 


ETIOLOGY  177 

Since  milk  is  the  great  carrier  of  pathogenic  bacteria  and  their  soluble 
toxins  into  the  intestinal  canal  of  the  infant,  it  follows  that  contaminated 
milk  is  by  far  the  most  important  cause  of  gastroenteric  intoxication  and 
that  all  of  the  conditions  therefore  which  predispose  to  the  contamination 
of  milk  are  important  etiological  factors  of  this  condition.  In  laying  stress 
upon  the  important  role  which  milk  plays  as  a  carrier  of  pathogenic  bac- 
teria, it  should  not  be  overlooked  that  such  bacteria  may  find  an  entrance 
into  the  intestinal  canal  of  the  infant  in  other  ways ;  in  the  water  it  drinks, 
on  the  foreign  bodies  it  puts  into  its  mouth  and  more  especially  in  the 
mucus  which  it  swallows.  I  have  been  much  impressed  in  recent  years  with 
the  fact  that  too  little  stress  has  been  laid  upon  this  latter  form  of  contami- 
nation. In  catarrhal  processes  of  the  nose,  pharynx  and  upper  air  passages 
which  occur  in  the  acute  infections,  large  quantities  of  mucus  are  secreted 
and  swallowed  by  the  infant.  This  mucus  contains  large  numbers  of  strep- 
tococci, staphylococci,  influenza  bacilli  and  other  microorganisms,  which 
may  infect  the  intestinal  mucosa  or  produce  a  pathological  fermentation  of 
food  stuffs  in  the  intestinal  canal,  thereby  producing  an  enteric  intoxica- 
tion. During  the  winter  season  this  is  perhaps  the  most  important  cause  of 
this  condition;  the  cases  of  so-called  intestinal  grippe  and  septic  enteritis 
follow  in  tlie  wake  of  these  intoxications. 

Notwithstanding  the  fact  that  we  speak  with  such  confidence  as  to  the 
role  which  bacteria  play  in  the  production  of  acute  gastroenteric  infections, 
yet  it  must  be  admitted  that,  in  spite  of  the  enormous  amount  of  work  that 
has  been  done  by  bacteriologists  in  the  study  of  the  normal  and  pathological 
intestinal  flora,  we  have  not  as  yet  been  able  to  associate  definite  gastro- 
enteric infections  with  specific  pathological  microorganisms,  nor  is  it  pos- 
ible  for  us  to  say  that  the  normal  intestinal  flora  may  not  under  patho- 
logical conditions  play  a  role  in  producing  these  conditions.  The  intestinal 
canal  of  the  newly  born  infant  is  free  from  microorganisms.  Within  a  few 
hours  after  birth,  however,  the  normal  intestinal  flora  begin  to  make  their 
appearance,  and  the  character  of  microorganisms  present  will  depend  upon 
the  food  of  the  infant.  If  the  infant  is  breast  fed  the  prevailing  types  are 
the  bacillus  bifidus  and  bacillus  acidophilus.  The  acidouric  group,  which 
flourishes  in  carbohydrate  media,  predominate  until  the  food  of  the  infant 
is  changed  to  cow's  milk  or  until  some  other  albuminous  food  is  added  to 
its  diet.  These  acid-forming  bacilli  protect  the  nursing  infant  against  at- 
tack from  putrefactive  organisms.  With  the  change  to  cow's  milk  and  albu- 
minous food  putrefactive  bacteria  of  the  colon  group  having  proteolytic 
action  make  their  appearance  and  in  part  replace  the  acid-forming  group; 
this  change  makes  the  child  more  susceptible  to  intestinal  infection  with 
pathogenic  microorganisms.  The  important  fact  to  be  borne  in  mind  is 
that  the  bacteria  which  inhabit  the  normal  intestine  serve  a  useful  purpose 
in  the  digestion  of  food  stuffs,  but  the  most  important  role  that  they  play 
is  in  preventing  the  infection  of  the  intestine  with  pathogenic  bacteria.  Tlie 
acid  fermentations  prevailing  in  the  normal  infant's  intestines  have  a  ten- 
dency to  prevent  and  destroy  putrefactive  processes.    It  is  also  important  to 


178  INTESTINAL    DISORDERS    OF    INFANCY 

bear  in  mind  that  the  putrefactive  processes  carried  on  by  pathogenic  bac- 
teria in  the  intestinal  canal  of  the  infant  may  be  modified  and  sometimes 
controlled  by  a  diet  poor  in  albumin  and  rich  in  carbohydrates,  the  carbo- 
hydrate foods  favoring  the  development  of  some  of  the  normal  acid-forming 
intestinal  bacteria  which  have  a  tendency  to  destroy  the  putrefactive  bacteria 
flourishing  in  the  proteins.  This  explains  in  part  the  value  of  carbohydrate 
foods  in  beginning  the  treatment  of  intestinal  indigestion ;  the  temporary 
success  which  follows  the  use  of  condensed  milk,  Nestle's  food  and  other 
foods  of  this  class  may  be  explained  in  this  way. 

Among  the  pathogenic  bacteria  which  may  produce  intestinal  infection 
the  streptococcus  enteritidis  deserves  special  mention,  and  Booker  is  entitled 
to  great  credit,  since  he  was  the  first  to  call  attention  to  the  role  which  this 
microorganism  plays  in  this  condition ;  he  found  it  not  only  in  the  stools, 
but  also  in  the  intestinal  canal  and  in  the  Avails  of  the  intestine,  and  in  the 
various  organs  of  infants  who  had  died  from  acute  enteric  infection. 
Escherich  confirmed  Booker's  observations  and  found  this  streptococcus  to 
be  the  cause  of  epidemics  of  this  disease,  but  notwithstanding  these  observa- 
tions there  is  no  clinical  picture  which  can  be  definitely  associated  with 
streptococci.  In  these  conditions  it  is  believed  that  various  species  of  strep- 
tococci are  active.  In  other  epidemics  the  staphylococcus  pyogenes  aureus 
and  albus  predominate.  Booker  also,  in  these  early  valuable  researches, 
called  attention  to  the  proteus  vulgaris  as  a  cause  of  enteric  infection.  It  was 
associated  especially  with  foul-smelling,  constipated,  grayish  stools  cov- 
ered with  mucus.  Brudzinski  later  observed  that  this  organism  disap- 
peared from  the  intestine  when  milk  foods  were  stopped  and  carbohydrates 
were  given,  and  he  also  found  that  the  same  result  could  be  obtained  by 
inoculating  the  food  of  the  infant  with  fresh  cultures  of  bacillus  lactis 
aerogenes.  This  is  an  example  of  controlling  a  pathological  fermentative 
process  by  the  introduction  of  bacteria  belonging  to  the  normal  intestinal 
flora.  Escherich,  who  is  one  of  the  most  valued  workers  in  this  field,  de- 
scribes a  "blue  bacillus,"  which  he  believed  to  be  the  etiological  factor  in  a 
severe  epidemic  of  this  disease.  He  also  believes,  with  a  number  of  other 
investigators,  that  the  bacillus  coli  communis  may  produce  intestinal  infec- 
tion. The  ameba  coli  is  associated  with  pathological  processes  in  the  infant 
similar  to  those  found  in  the  adult.  The  influenza  or  Pfeiffer  bacillus  is 
now  generally  recognized  as  one  of  the  common  causes  of  intestinal  infec- 
tion, especially  during  the  winter  months.  This  bacillus  may  produce  a 
more  or  less  severe  catarrhal  condition  of  the  intestinal  mucosa  which  is 
commonly  known  as  intestinal  grippe.  The  bacillus  Welchii,  or  gas  bacillus, 
is  believed  to  be  commonly  associated  with  putrefactive  intestinal  disturb- 
ances. 

In  recent  years  the  Shiga  bacillus  has  been  definitely  associated  with 
the  etiology  and  pathology  of  gastroenteric  infections  both  in  the  infant 
and  in  the  adult.  This  bacillus,  named  for  its  Japanese  discoverer,  was 
demonstrated  to  be  the  causative  factor  of  epidemic  dysentery  in  the  adult. 
Flexner  and  his  associates  in  this  country,  and  a  large  number  of  observers 


ETIOLOGY  179 

the  world  over,  have  shown  that  the  Shiga  hacillus  plays  a  pathological  role 
in  the  gastrointestinal  diseases  of  infancy,  but  this  bacillus  is  not  asso- 
ciated definitely  with  any  distinct  symptom  group.  It  has  been  found  in 
cases  of  gastroenteric  infection  and  in  mild  and  severe  cases  of  enterocolitis. 
The  more  recent  investigators,  however,  believe  that  it  is  very  definitely 
associated  with  the  pathological  processes  in  acute  enterocolitis  in  which  the 
stools  contain  blood  and  mucus.  In  some  of  these  cases  it  is  possible  to 
demonstrate  the  specific  agglutinin  reaction  to  the  Shiga  bacillus  in  the 
blood  of  the  patient.  This  reaction,  it  is  assumed,  definitely  associates  the 
Shiga  bacillus  with  the  pathological  process  in  the  intestine.  Flexner  and 
his  associates  determined  that  there  were  two  varieties  of  the  Shiga  bacillus. 
One  of  these,  the  true  Shiga  bacillus,  is  spoken  of  as  the  alkaline  type;  it 
does  not  ferment  in  mannit  media ;  the  other,  the  Flexner  or  acid  type, 
does  ferment  in  mannit  media,  and  of  the  two  it  is  more  closely  associated 
with  infantile  enterocolitis.  But  in  this  disease  it  is  now  recognized  that 
streptococci  and  the  colon  bacillus  also  enter  into  the  pathological  process. 

The  infectious  nature  of  the  diarrheal  diseases  of  infancy  should  be 
insisted  upon  in  order  to  insure  proper  care  in  handling  the  intestinal  dis- 
charges. While  it  is  true  that  there  is  comparatively  little  danger  that 
bacteria,  producing  intestinal  disorders,  will  pass  directly  from  one  infant 
to  another,  it  is  also  true  that  the  careless  handling  of  the  intestinal  dis- 
charges may  so  contaminate  the  surroundings  of  the  infant  suffering  from 
diarrhea  that  other  infants  living  in  the  same  room  will  be  in  great  danger 
of  gastrointestinal  infection.  In  hospitals  and  tenement  houses  infection 
may  be  a  potent  factor  in  spreading  the  diarrheal  diseases  of  infancy. 

Age  is  the  all-important  predisposing  cause  of  the  intestinal  disorders 
of  infancy.  The  vast  majority  of  these  cases  occur  during  the  first  or 
second  year  of  life.  After  the  second  year  the  predisposition  to  these  con- 
ditions so  rapidly  diminishes  with  the  age  of  the  child  that  they  are  com- 
paratively infrequent,  and  when  they  do  occur  are  much  less  serious  in 
character.  When  it  is  realized  that  children  three  or  four  years  of  age,  tak- 
ing the  same  food  and  living  under  the  same  hygienic  surroundings,  are 
comparatively  exempt,  the  importance  of  age  as  a  predisposing  factor  be- 
comes apparent.  This  susceptibility  on  the  part  of  infants  to  gastroenteric 
diseases  perhaps  may  be  accounted  for  by  their  lack  of  resistance  to  fer- 
mentative processes  in  the  intestinal  canal  and  to  the  resulting  catarrhal 
processes  which  follow^  these  fermentations,  and  by  their  greater  suscepti- 
bility to  the  action  of  soluble  bacterial  poisons.  These  soluble  poisons,  act- 
ing upon  the  undeveloped  and  immature  nervous  system  of  the  infant,  pro- 
duce high  fever,  convulsions,  and  other  severe  constitutional  symptoms, 
which  the  better-balanced  nervous  system  of  the  child  resists  to  such  an 
extent  that  these  toxic  symptoms  are  comparatively  slight.  It  follows, 
therefore,  that  even  normal  infants  should  be  protected  in  every  possible 
way  from  all  the  exciting  and  predisposing  causes  of  gastroenteric  diseases. 

The  heat  of  summer  is  such  an  important  factor  in  producing  the  in- 
testinal disorders  of  infancy  that  these  conditions  are  not  uncommonly 


180  INTESTINAL   DISORDEES    OF    INFANCY 

spoken  of  as  "summer  complaint."  Infant  mortality,  so  enormously  in- 
creased during  the  hot  summer  months,  is  largely  due  to  the  prevalence  of 
gastroenteric  diseases  during  that  period  of  the  year.  Summer  heat  pro- 
motes food  contamination;  among  the  poor  of  our  large  cities  who  have 
not  the  means  to  procure  clean  cow's  milk,  nor  the  facilities  for  keeping  it 
clean  even  if  it  were  furnished  them,  milk  is  so  rapidly  contaminated  by 
bacteria  that  it  soon  becomes  an  unsafe  food  for  infant  feeding,  and  is 
therefore  responsible  for  a  large  percentage  of  the  cases  of  gastroenteric 
infection.  Even  among  the  well-to-do,  who  have  the  facilities  for  obtain- 
ing and  caring  for  clean  milk,  the  difficulties  which  prolonged  hot  weather 
adds  to  the  care  of  keeping  milk  wholesome  make  milk  contamination  and 
the  resulting  intestinal  disorders  of  not  uncommon  occurrence.  The  heat 
of  summer  also  acts  directly  on  the  infant,  diminishing  its  digestive  capac- 
ity and  its  normal  resistance  to  these  diseases.  It  is  also  probable,  as 
Forchheimer  has  taught  for  many  years,  that  many  of  the  cases  of  so-called 
gastroenteric  intoxication  are  due  directly  to  the  effect  of  heat.  That  is  to 
say,  the  infant  primarily  suffers  a  heat-stroke,  with  high  fever,  great  pros- 
tration, and  secondarily  an  acute  intestinal  disorder;  the  latter  condition 
continuing  after  the  infant  has  recovered  from  the  primary  effects  of  the 
heat  stroke. 

Humidity  or  the  amount  of  rainfall,  according  to  Seibert  and  others 
who  have  investigated  this  subject  statistically,  has  little  to  do  with  the 
mortality  of  this  disease,  and  it  is  difficult  to  see  how  this  cause  could  act 
deleteriously  except,  perhaps,  in  housing  infants  in  unhygienic  quarters 
on  rainy  days,  and  this  might  easily  be  offset  by  the  fact  that  rain  cleans 
the  air  and  streets  and  reduces  the  temperature. 

Bad  hygienic  surroundings  is  an  important  cause  of  gastrointestinal  dis- 
orders in  infancy.  This  fact  is  brought  home  to  us  by  the  enormous  death 
rate  of  infants  among  the  tenement  house  population  of  our  large  cities 
during  the  hot  summer  months.  Infants  who  must  pass  their  nights  in  ill- 
ventilated,  unclean  rooms  and  their  days  in  the  surrounding  dirty  streets, 
have  comparatively  little  chance  to  escape  the  dangers  of  food  contamina- 
tion. Bad  hygienic  surroundings  not  only  enormously  increase  the  danger 
which  surrounds  these  infants  by  increasing  their  opportunities  for  infec- 
tion, but  also  predispose  them  to  gastroenteric  diseases  by  reason  of  the 
fact  that  they  have  lived  throughout  the  year  in  close,  badly  ventilated 
quarters,  with  little  sunlight  and  fresh  air,  and  have  therefore  feeble  diges- 
tive capacities  and  diminished  powers  of  resistance. 

PREVENTIVE  TREATMENT 

Since  the  acute  intestinal  disorders  of  infancy  are  the  great  causes  of 
mortality  during  this  period  of  life,  every  infant  should  be  cared  for  with 
special  reference  to  the  prevention  of  these  diseases.  In  accomplishing 
this  end  the  physician's  prime  object  will  be  to  place  the  infant  upon  the 
most  available  food  for  strengthening  its  digestive  capacity  and  improving 


PEEVENTIYE  TKEATMENT  181 

its  nutritional  condition.  All  breast-fed  babies  should,  if  possible,  be  kept 
upon  breast  milk  as  an  exclusive  food  during  the  hot  summer  months,  and, 
if  the  breast  milk  be  insufficient  for  this  purpose,  mixed  feeding,  as  fully 
outlined  in  a  previous  chapter,  should  be  resorted  to.  By  this  method  the 
infant  takes  sufficient  modified  milk,  following  a  number  or  all  of  the  breast 
feedings,  to  supply  its  nutritional  demands.  The  importance  of  a  little 
breast  milk  to  assist  in  the  digestion  of  the  cow's  milk  and  to  maintain 
the  normal  intestinal  flora  is  of  special  importance  during  hot  weather. 
Artificially  fed  children  should  be  even  more  carefully  fed  according  to  the 
principles  outlined  under  infant  feeding.  Well  infants  should  be  fed  at 
regular  intervals  on  a  food  formula  suitable  to  their  age,  weight  and  diges- 
tion, great  care  being  taken,  especially  in  hot  weather,  not  to  overfeed  either 
in  quantity  of  food  taken  at  a  feeding  or  in  the  number  of  calories  given  in 
twenty-four  hours.  As  the  hot  weather  approaches  and  the  heat  increases, 
the  normal  infant,  thriving  on  a  wholesome  food  formula,  should  be  let 
alone,  no  attempt  being  made  to  increase  the  strength  of  the  formula  or 
to  add  new  foods  while  the  infant  is  battling  with  the  depressing  effects  of 
the  heat.  Be  satisfied  with  having  a  well  baby  during  the  two  or  three 
months  of  hot  weather  even  if  it  gains  little  or  nothing  in  weight.  It  is 
wise  to  discard  the  scales  during  this  period,  lest  the  ambitious  mother  at- 
tempt, by  the  addition  or  increase  of  foods,  to  maintain  in  the  infant  the 
same  increase  in  weight  which  it  was  making  under  more  favorable  con- 
ditions. 

Malnourished,  delicate  infants  with  feeble  digestive  powers  are  ofttimes 
not  able  to  take  the  same  amount  of  food  during  the  summer  months  which 
they  have  previously  thrived  upon.  With  such  infants  it  is  wise,  therefore, 
as  the  hot  weather  approaches,  to  slightly  reduce  the  amount  of  fat  in  the 
food  and  the  quantity  of  food  at  each  feeding.  This  precautionary  meas- 
ure may  prevent  indigestion,  subsequent  infection,  and  gastrointestinal 
catarrh,  and  the  infant  may  remain  well  even  though  it  fails  to  gain  in 
weight.  All  infants,  suffering  from  rickets  and  other  malnutritions,  as  a 
result  of  feeding  with  condensed  milk  and  the  proprietary  foods,  should 
during  the  winter  months  be  placed  upon  a  proper  milk  formula,  so  that 
their  intestinal  digestions  may  be  gradually  strengthened  and  educated  to 
the  digestion  of  a  more  wholesome  food,  which  will  gradually  overcome  their 
malnutrition  and  increase  their  powers  of  resistance.  These  measures  will 
better  prepare  them  to  withstand  the  depressing  effects  of  hot  weather  and 
perhaps  enable  them  to  resist  the  infection  to  which  all  are  more  or  less 
exposed.  The  importance  of  this  line  of  treatment  is  recognized,  since 
feeble,  malnourished  infants  have  much  less  chance  for  life  when  they 
are  attacked  by  these  diseases. 

In  the  prevention  of  the  intestinal  disorders  of  infancy  the  physician 
should  recognize  the  fact  that  clean,  wholesome  food  is  the  most  important 
means  for  accomplishing  this  end.  The  basis  of  all  artificially  prepared 
infant  foods  should  be  clean,  raw  milk.  If  this  be  not  possible,  pasteurized 
milk,  and,  where  the  conditions  are  such  that  this  is  not  available,  then 


182  INTESTINAL    DISOEDEKS    OF    INFANCY 

sterilized  milk.  Among  the  very  poor  in  our  large  cities  it  may  be  neces- 
sary to  use  condensed  milk  or  the  proprietary  milk-foods,  such  as  malted 
milk  or  Nestle's  food,  for  a  few  months  during  the  summer;  the  physician 
deciding  in  the  individual  case  that  it  is  better  to  expose  the  infant  to  the 
dangers  of  rickets  and  other  malnutritions  which  result  from  the  continu- 
ous use  of  these  foods,  rather  tlian  to  expose  it  to  the  greater  danger  from 
gastroenteric  infections,  which  will  almost  certainly  result  if  the  infant  is 
fed  on  grocery  milk  or  other  cheap  grades  of  milk  sold  in  the  tenement 
districts.  These  milks,  greatly  contaminated  with  microorganisms,  cared 
for  without  ice,  and  handled  under  unhygienic  surroundings,  expose  the 
infant  to  dangers  from  gastrointestinal  diseases  beside  which  the  malnu- 
tritions coming  from  ill-balanced,  patent,  sterile  foods  are  of  little  conse- 
quence. The  use  of  condensed  milk  and  the  proprietary  foods  may,  there- 
fore, be  a  life-saving  measure  among  the  very  poor  of  our  cities  during  the 
months  of  summer.  But  if  one  decides  to  give  an  infant  rickets  and  other 
malnutritions  in  order  to  save  its  life,  he  should  also  feel  the  responsibility 
of  curing  the  infant  of  these  malnutritions  as  soon  as  the  weather  con- 
ditions will  permit  the  giving  of  codliver  oil  and  a  return  to  a  wholesome 
milk  formula.  The  necessity  for  the  use  of  condensed  milk  and  the  pro- 
prietary foods  among  the  poor  might  be  greatly  diminished  if,  as  Kerley 
suggests,  tenement  house  mothers  were  furnished  with  sterilized  milk  and 
ice  to  preserve  it,  and  if  at  the  same  time  they  could  be  systematically 
educated  in  the  care  and  feeding  of  their  infants.  Dr.  \Vm.  H.  Park,  of 
the  New  York  Health  Department,  during  the  summer  of  1902,  demon- 
strated that  this  plan  was  altogether  feasible.  He  selected  fifty  tenement 
children  under  one  year  of  age,  furnished  them  with  sterilized  milk  and 
ice,  placed  them  under  the  supervision  of  physicians  who  instructed  the 
mothers  in  the  care  of  the  milk  and  the  feeding-bottles,  and  gave  the  in- 
fants necessary  treatment  when  they  were  ill,  and  as  a  result  all  of  these 
infants  passed  through  the  summer  in  safety.  If  our  municipal  authori- 
ties and  organized  charities  would  undertake  this  same  kind  of  work  the 
infant  mortality  from  intestinal  diseases  during  the  summer  months  would 
be  materially  diminished. 

As  heat  is  so  potent  a  factor  in  producing  the  intestinal  disorders  of 
infancy  it  follows  that  all  infants  during  the  hot  summer  montlis  should 
be  kept  as  cool  as  possible.  Among  the  more  prosperous  of  our  population, 
and  especially  those  who  live  in  cities,  a  radical  change  of  climate  is  ad- 
visable. When  the  only  thing  to  be  considered  is  the  welfare  of  the  infant, 
it  should  be  sent  to  some  cool  country  place  in  our  northern  country  or  to 
the  mountains  or  seashore.  If  this  be  not  feasible  it  may  be  taken  for  the 
summer  out  of  the  city  into  the  adjoining  country,  where  the  air  will  be 
purer  and  cooler  and  the  surroundings  cleaner.  If  this  cannot  be  accom- 
plished it  should  spend  as  much  of  the  day  as  possible  out-of-doors  on 
porches  or  in  shady  yards  and  parks.  In  short,  it  should  pass  its  time  day 
and  night  in  the  coolest,  purest  air  available. 

Bathing  in  cool  water  promotes  sleep,  acts  as  a  tonic  and  stimulates  the 


SYMPTOMATOLOGY  183 

circulation,  and  is  of  great  value  in  preventing  gastrointestinal  disturb- 
ances. During  the  very  hot  weather  morning  and  evening  baths  are  ad- 
visable. The  clothing  of  the  infant  should  be  such  as  not  to  oppress  it, 
and  for  those  infants  who  are  compelled  to  remain  in  the  city  very  little 
clothing  is  needed.  Too  much  clothing  is  a  common  cause  of  overheating, 
skin  irritation,  sleeplessness,  and  indigestion,  all  of  which  predispose  the 
infant  to  serious  gastrointestinal  disturbances.  Bare  feet,  legs  and  arms, 
light  napkins,  and  the  thinnest  possible  covering  for  the  body  are  all  that 
are  necessary  on  very  hot  days ;  on  damp  and  cool  days  slightly  more  cloth- 
ing may  be  needed.  The  skin  irritation  which  results  from  heat  and  heavy 
clothing  causes  the  infant  to  be  restless,  irritable,  sleepless,  and  thereby  pre- 
disposes it  to  intestinal  disorders.  This  condition  may  be  corrected  by 
clothing  and  bathing  the  body  as  above  noted  and  dusting  it  with  a  powder 
made  of  equal  parts  of  starch  and  oxid  of  zinc. 

In  the  prevention  of  the  intestinal  disorders  of  infancy  it  is  all-im- 
portant that  prompt  attention  be  given  to  the  earliest  symptoms  of  gastric 
or  intestinal  discomfort.  If  infants  had  proper  medical  attention  as  soon 
as  vomiting,  diarrhea,  or  fever  appeared,  then  most  of  these  cases  would 
never  pass  beyond  the  stage  of  simple  gastric  or  intestinal  indigestion. 
Mothers  should  be  taught  that  on  the  appearance  of  these  symptoms  a 
cathartic  should  be  given,  all  food  should  be  stopped,  and  a  physician  should 
be  consulted. 

CHAPTER  XX 
ACUTE    INTESTINAL    INDIGESTION 

Pathology. — There  are  no  lesions  in  this  disease  beyond  the  temporary 
congestion  and  irritation  of  the  mucous  membrane  which  result  from 
offensive  material  in  the  intestinal  canal,  when  this  remains  long  enough 
to  produce  a  catarrhal  inflammation  we  have  passed  beyond  the  stage  of 
acute  intestinal  indigestion.  The  clinician  must,  therefore,  ofttimes  await 
the  result  of  twenty-four  hours  of  treatment  to  determine  whether  he  has 
to  deal  with  an  acute  intestinal  indigestion  or  an  intestinal  catarrh. 

Symptomatology. — Very  commonly  nausea,  vomiting,  gastric  discom- 
fort, and  gastric  pain  may  precede  the  intestinal  symptoms.  This  is  es- 
pecially true  if  the  attack  be  a  sudden  one,  occurring  in  a  normal  child, 
produced  by  some  notable  error  in  diet.  In  feeble  infants  with  weak  di- 
gestive capacity,  intestinal  indigestion  usually  develops  without  preliminary 
gastric  disturbance. 

Diarrhea  is  the  most  common  and  characteristic  symptom,  although  it 
is  not  always  the  first,  and  constipation  may  persist  throughout  the  attack. 
Fever  and  nervous  symptoms  may  mark  the  onset  of  the  attack,  and  the 
physician  may  be  in  doubt  as  to  the  cause  of  these  symptoms  until  the 
diarrhea  assists  in  making  the  diagnosis.  The  very  wise  and  almost  uni- 
versal custom  of  giving  a  cathartic  to  a  child  suffering  acutely  from  fever 


184  ACUTE  INTESTINAL  INDIGESTION 

and  nervous  symptoms  results  in  unloading  the  bowels,  and  from  the 
character  of  these  intestinal  discharges  the  diagnosis  is  made.  The  stools 
are  commonly  alkaline  in  reaction,  green  in  color,  and  foul  in  odor,  but 
where  they  are  markedly  acid  in  reaction  and  sour  in  odor  the  diarrhea  is 
more  pronounced,  the  constitutional  symptoms  less  severe,  and  the  buttocks 
and  adjacent  parts  red  and  irritated  from  the  discharges.  Mucus  and  un- 
digested food  are  present  and  either  small  soft  curds  (fat)  or  large  tough 
curds  (casein)  may  be  seen. 

The  height  of  the  fever  depends  largely  upon  the  age  and  nutrition  of 
the  infant;  the  younger  and  more  malnourished  it  is  the  higher  the  fever. 
The  severity  of  the  exciting  cause  also  influences  the  height  of  the  fever, 
which  may  vary  from  101°  to  105°  F.  It  falls,  however,  almost  imme- 
diately after  the  bowels  have  been  unloaded  and  remains  normal  under 
proper  treatment;  its  duration  should  not  exceed  one  or  two  days. 

The  nervous  symptoms  depend  largely  upon  the  age  and  nutrition  of 
the  child,  as  well  as  upon  the  severity  of  the  exciting  cause.  A  young, 
feeble,  rachitic  infant  may  have  a  convulsion  from  an  exciting  cause  that 
could  produce  only  sleeplessness  and  irritability  in  an  older,  normal  infant. 
One  may  sa}^  therefore,  that  the  younger  the  infant  and  the  more  mal- 
nourished it  is,  the  more  severe  will  be  the  nervous  symptoms,  which  sud- 
denly subside  when  the  intestinal  canal  is  cleared.  Following  the  fall  in 
the  fever  and  the  subsidence  of  the  nervous  symptoms,  the  child  may  be 
prostrated  and  its  face  show  the  results  of  the  acute  illness  of  the  previous 
day. 

Pain  is  a  frequent  symptom.  Intestinal  colic  is  especially  common  in 
young,  malnourished  infants  suifering  from  attacks  of  acute  intestinal  in- 
digestion ;  it  is  produced,  as  a  rule,  by  flatulency,  and  the  abdomen  is  there- 
fore more  or  less  distended  and  tympanitic,  but  it  may  also  result  from 
irregular  and  excessive  peristalsis.  In  the  intervals  between  the  attacks 
of  colic,  the  infant  remains  quiet  for  a  time  and  then  the  paroxysm  is  re- 
newed; it  cries  fiercely,  draws  up  its  legs,  twists  its  body,  and  gives  every 
evidence  that  it  is  suffering  great  pain.  It  is  also  a  notable  fact  that  intes- 
tinal colic  is  a  prominent  feature  of  acute  intestinal  indigestion  in  older 
children;  in  these  cases  the  pain  may  be  very  severe,  the  child  screaming 
and  doubling  himself  up  in  his  paroxysm  of  pain,  which  comes  and  goes  as 
it  does  in  the  young  and  feeble  infant.  In  older  children  the  diarrhea, 
fever,  and  nervous  symptoms  are  comparatively  slight  and  the  patients  are 
sleepless,  restless,  and  irritable.  The  cathartic  which  carries  away  the 
offending  material  commonly  relieves  all  symptoms. 

Symptom  Groups. — Czerny,  Keller,  Finkelstein,  Langstein,  Meyer  and 
others  attempt  a  differentiation  of  the  symptom  groups  produced  by  indiges- 
tion from  the  different  ingredients  of  milk.  These  groups  represent  "food 
injuries"  not  only  to  the  digestive  organs,  but  also  to  the  metabolism  of  the 
infant,  from  the  intake  beyond  the  point  of  tolerance  of  the  fat,  carbohy- 
drates, whey  salts  and  proteins  in  its  food.  That  is,  overfeeding  with  fat, 
carbohydrates,  whey  salts  or  proteins  produces  a  distinct  symptom  complex. 


SYMPTOM  GEOUPS  18S 

which  is  of  great  value  from  a  clinical  standpoint  in  that  it  enables  one,  in  a 
given  case,  to  withdraw  from  the  food  the  special  ingredient  causing  the 
trouble.  If  the  symptoms  indicate  fat  indigestion,  then  the  fats  are  to  be 
excluded  from  the  diet  and  the  carbohydrates  and  proteins  continued ;  if,  on 
the  other  hand,  the  symptoms  indicate  a  sugar  or  a  protein  indigestion,  the 
offending  ingredient  is  to  be  discontinued  and  the  food  of  the  infant  made 
up  largely  of  the  other  two  important  ingredients.  By  this  method  the 
infant  will  not  be  unnecessarily  starved  over  a  long  period  of  time  when 
in  fact  there  is  only  one  ingredient  which  it  cannot  digest  and  properly 
metabolize.  There  must,  however,  in  these,  as  in  all  cases  of  acute  indiges- 
tion, be  a  period  of  complete  rest  and  cleansing  of  the  intestinal  canal,  and 
then  the  special  formula,  which  the  symptoms  indicate  will  be  tolerated, 
should  be  prescribed.  It  is  an  interesting  fact  that,  following  these  "food 
injuries,"  which  are  so  common  in  both  acute  and  chronic  intestinal  indiges- 
tion, the  infant's  tolerance  for  the  food  ingredient  which  produced  the 
injury  is  very  greatly  diminished,  so  that  it  may  be  many  weeks  or  months 
before  it  is  again  able  to  digest  and  metabolize  the  same  quantity  of  this 
ingredient  which  it  took  before  the  illness  ("injury")  occurred.  For  ex- 
ample, an  infant  that  has  been  thriving  upon  a  food  formula  which  con- 
tained 3  or  more  per  cent,  of  fat  may,  following  an  attack  of  indiges- 
tion, not  be  able  to  take  more  than  i^  or  1  per  cent,  of  fat ;  yet  this  infant 
may  thrive  on  high  percentages  of  carbohydrates  and  proteins  during  the 
many  weeks  it  is  slowly  recovering  its  tolerance  for  fat  (cream).  This 
diminished  tolerance,  which  may  be  so  suddenly  developed  for  the  food  in- 
gredients of  milk,  is  strongly  suggestive  of  the  phenomena  of  anaphylaxis 
and  is  perhaps  similar  in  its  pathology  to  many  of  the  so-called  food  idio- 
syncrasies with  which  we  have  long  been  familiar.  The  poisoning  which 
follows  the  taking  of  certain  foods  (such  as  eggs,  fish,  etc.)  in  certain  chil- 
dren, and  even  in  adults,  is  perhaps  due  to  an  inherited  or  acquired  lack 
of  systemic  tolerance  for  these  particular  foods.  Whatever  be  the  explana- 
tion, the  fact  remains  that  intolerance  for  the  various  food  ingredients  of 
milk  is  very  commonly  associated  with  the  intestinal  disorders  of  infancy 
and  is  one  of  the  important  factors  in  aggravating  and  prolonging  them. 
The  symptom  groups,  however,  associated  with  the  intolerance  of  fat, 
carbohydrates,  whey  salts  and  proteins  are  not  always  clearly  defined;  this 
is  in  part  due  to  the  fact  that  different  degrees  of  intolerance  for  the 
various  food  ingredients  of  milk  may  occur  in  the  same  infant,  and  then 
again  it  appears  that  in  certain  infants  the  carbohydrates  may  be  tolerated 
when  the  food  has  a  low  fat  content,  or  the  fats  may  be  tolerated  when  the 
food  has  a  low  carbohydrate  content.  The  proteins,  especially  the  casein, 
apparently  do  not  aggravate  the  intolerance  of  the  infant  for  either  fats  or 
carbohydrates,  but  protein  intolerance  is  aggravated  by  fat  and  alleviated 
by  carbohydrates.  The  above  discussion  will,  the  author  hopes,  materially 
assist  in  determining  the  practical  value  of  the  following  syndromes. 

Fat  Indigestion. — Fat  indigestion  is  very  common  in  the  gastroin- 
testinal disorders  of  infancy,  and  apart  from  the  ordinary  symptoms  of 


186  ACUTE   INTESTINAL  INDIGESTION 

indigestion  and  intoxication  above  noted,  it  has  a  more  or  less  distinct 
symptom  group.  There  is  commonly  a  history  of  excessive  quantities  of 
fat  (cream)  taken.  The  infant  is  malnourished,  has  a  pale,  muddy  com- 
plexion with  dark  circles  under  the  eyes,  has  a  coated  tongue  and  fetid 
breath.  Gastric  disturbance  and  vomiting  are  common,  constipation  is 
nearly  always  present,  but  it  sometimes  alternates  with  diarrhea.  The 
stools  are,  as  a  rule,  small,  fragmentary,  dry,  and  crumbly,  and  are  either 
white  or  light  yellow  in  color.  They  may  have  a  shiny,  oily  look  and  the 
odor  of  butyric  acid  may  be  noted.  A  microscopic  examination  will  reveal 
an  excess  of  neutral  fats,  fatty  acids,  and  soaps.  The  urine  may  have  an 
ammoniacal  odor.  An  inability  to  digest  and  assimilate  fat  is  most  com- 
monly associated  with  acute  and  chronic  intestinal  indigestion,  the  latter 
resulting  in  marasmus  or  atrophy. 

Sugar  Indigestion. — Sugar  indigestion  is  very  commonly  associated 
with  the  gastrointestinal  disorders  of  infancy;  in  some  instances  it  is  the 
important  exciting  cause,  in  others  it  is  a  contributing  factor  which  aggra- 
vates and  prolongs  the  disease.  In  these  cases  there  is  usually  a  history  of 
an  excessive  intake  of  sugars  (sweets) ;  in  young  infants  milk-sugar  is  the 
common  cause.  Diarrhea  is  the  most  notable  symptom ;  the  stools  are  fre- 
quent, copious,  watery,  acid,  have  a  sour  odor,  and  irritate  the  skin  of  the 
buttocks;  they  are  usually  light  green  in  color  and  may  contain  neither 
mucus  nor  curds;  gas  formation,  producing  tympanites,  is  usually  present. 
Vomiting  and  regurgitation  of  sour  material  are  common  symptoms.  The 
infant  loses  weight,  is  irritable  and  fretful,  urticaria  may  occur,  and  fever 
may  be  present.  The  urine  may  contain  lactose,  and  acetone  and  diacetic 
acid  are  frequently  found.  In  older  children  a  sugar  intoxication  is  very 
commonly  manifested  by  an  attack  of  urticaria,  recurrent  vomiting,  mi- 
graine, or  asthma,  and  in  such  cases  the  finding  of  acetone  and  diacetic 
acid  in  the  urine  strongly  favors  this  diagnosis.  In  severe  forms  of  sugar 
intoxication,  described  by  Finkelstein  and  others,  fever,  profound  nervous 
symptoms,  and  a  well-marked  polymorphonuclear  leukocytosis  are  present. 
In  these  cases  sugar  intoxication  is  commonly  associated  with  an  inability 
to  metabolize  the  whey  salts,  which  are  believed  to  be  in  part  responsible 
for  the  rise  in  temperature.  This  group  comprehends  many  of  the  cases 
which  develop  into  severe  intestinal  toxemia,  the  symptom  group  of  which 
is  controlled  by  eliminating  the  sugars  and  whey  salts  from  the  food,  and 
is  again  aggravated  by  the  addition  of  these  same  ingredients. 

Protein  Indigestion. — Protein  indigestion  is  not  as  common  as  it 
was  thought  to.  be  a  few  years  ago;  it  is,  however,  not  infrequent.  The 
disturbance  is  characteri.zed  by  the  ordinary  signs  of  intestinal  indigestion 
previously  noted.  There  is  commonly  a  history  of  an  excessive  intake  of 
proteins,  the  infant  loses  in  weight,  is  flabby,  anemic,  and  may  have  either 
constipation  or  diarrhea.  The  stools,  however,  always  contain  large,  tougli 
casein  curds;  in  some  cases  not  more  than  one  or  two  of  these  large  curds 
are  passed  in  twenty-four  hours.  The  stools  are  usually  alkaline  and  foul 
smelling.     Casein  indigestion  very  commonly  leads  up  to  a  casein  putre- 


TEEATMENT  187 

faction  and  then  we  may  have  the  fever,  diarrhea,  and  severe  nervous  symp- 
toms sometimes  associated  with  this  form  of  intoxication. 

Diagnosis. — The  diagnosis  of  acute  intestinal  indigestion  from  acute 
intestinal  intoxication  and  intestinal  catarrh  is  determined  by  the  results 
of  the  treatment.  If  the  constitutional  symptoms  yield  at  once  to  proper 
cathartic  medication  and  proper  diet,  the  diagnosis  of  intestinal  indigestion 
is  confirmed. 

The  prognosis  is  good.  In  feeble  rachitic  infants,  however,  convulsions 
may  occur  and  jeopardize  life.  When  neglected  or  improperly  treated  this 
condition  may  be  the  cause  of  an  intestinal  catarrh  or  may  excite  an  in- 
testinal toxemia,  either  of  which  conditions  may  place  the  child's  life  in 
jeopardy. 

Treatment. — From  what  has  been  said  it  is  evident  that  in  feeble,  mal- 
nourished children  who  are  markedly  predisposed  to  this  disease  the  pro- 
phylactic treatment  is  most  important.  With  this  type  of  child  the  diet 
should  be  closely  watched  and  regulated  to  suit  existing  conditions.  The 
food  formula  should  be  modified  with  great  care  to  meet  the  needs  of  the 
individual  infant,  and  as  the  summer  approaches  special  care  should  be 
exercised  to  protect  it  from  the  depressing  effects  of  the  heat.  If  it  be  a 
city  child  it  should,  if  possible,  be  sent  into  the  country  or  placed  under  the 
best  possible  climatic  conditions. 

In  dealing  with  an  individual  attack  a  cathartic  should  be  given,  and 
of  all  cathartics  castor-oil  is  preferable.  Even  if  the  infant  has  a  disturbed 
stomach  and  the  castor-oil  provokes  vomiting,  the  emptying  of  the  stomach 
will  be  beneficial,  and  in  this  event  as  soon  as  the  vomiting  has  subsided 
calomel  may  be  given.  It  is  preferable  to  give  the  calomel  in  small  doses, 
at  frequent  intervals,  until  a  grain  or  a  grain  and  a  half  has  been  given, 
and  an  hour  or  two  after  the  last  dose  of  calomel  a  second  dose  of  castor- 
oil  may  be  given.  If  this  is  again  vomited,  milk  of  magnesia  in  teaspoon- 
ful  doses,  at  three  or  four-hour  intervals,  may  be  given  until  the  intestinal 
canal  is  cleared.  If,  however,  the  preliminary  dose  of  castor-oil  is  retained 
no  other  cathartic  is  needed.  An  enema  should  be  given  even  before  the 
cathartic;  this  is  especially  indicated  if  the  infant  is  suffering  from  colic. 
The  injection  of  water  into  the  colon  will,  as  a  rule,  unload  the  lower 
bowel  and,  in  the  great  majority  of  instances,  relieve  the  intestinal  pain  by 
causing  a  discharge  of  gas.  The  enema  and  cathartic  having  been  given, 
the  child  is  kept  as  quiet  as  possible,  and  if  it  is  still  suffering  it  may  have 
dry  heat  applied  to  its  abdomen ;  this  may  be  done  with  a  hot-water  bottle, 
the  hops  bag,  or  hot  flannel.  If  the  feet  be  cold  they  also  may  be  warmed 
by  the  application  of  dry  heat.  The  cardinal  rule  in  the  treatment  of  these 
cases  is  absolute  rest  to  the  stomach  for  twelve  or  twenty-four  hours  or  at 
least  until  the  cathartic  has  thoroughly  acted.  Fortunately,  in  the  begin- 
ning the  child  has  no  appetite  and  the  thirst  which  accompanies  the  fever 
may  be  satisfied  by  giving  small  quantities  of  water.  It  is  better,  however, 
not  to  begin  even  the  water  until  two  or  three  hours  after  the  preliminary 
cathartic.     The  child  can,  as  a  rule,  be  kept  upon  water  for  twelve  or 


188  ACUTE  INTESTINAL  INDIGESTION 

twenty-four  hours  and  after  this,  for  the  next  day,  it  may  be  given  barley 
water,  meat  juice,  or  thin  beef  or  mutton  broth.  On  the  third  day  the  diet 
may  be  whey  or  fat-free  milk  in  small  quantities;  the  milk  should  be 
largely  diluted,  with  dextrinized  barley  water,  and  the  quantity  gradually 
increased  as  the  child  convalesces.  In  these  cases  the  tolerance  for  carbo- 
hydrates and  proteins  is  not  reduced,  and  for  this  reason  most  of  these 
eases  do  well  upon  a  mixture  of  skimmed  milk  and  a  thick  dextrinized 
gruel  until  they  can  gradually  be  returned  to  their  original  food  formulas. 
If  the  symptoms  indicate  some  definite  form  of  food  intolerance,  a  food 
formula  very  weak  in  fat,  sugars  or  protein,  as  the  individual  case  may 
require,  may  be  prescribed.  In  severe  cases  the  infant  may  have  to  be  un- 
derfed for  a  number  of  weeks  before  it  is  finally  placed  upon  a  food  formula 
suited  to  its  age  and  weight. 

There  is  little  to  add  in  the  way  of  medicinal  treatment  for  these  cases. 
A  diastase  such  as  liquid  takadiastase  may  be  added  to  the  barley  water, 
and  simple  chalk  mixture  may  be  given  if  gastric  or  intestinal  irritation 
continues.  On  the  fourth  or  fifth  day  it  is  advisable  to  give  a  sec- 
ond dose  of  castor  oil,  and  if  this  does  not  produce  mucous  discharges  the 
child  may  be  considered  as  fairly  convalescent.  If,  however,  mucous  dis- 
charges are  produced  by  the  castor  oil,  careful  dietetic  treatment  should  be 
continued  for  a  few  days  longer  and  a  third  dose  of  oil  given;  these  cases 
are  bordering  on  acute  intestinal  intoxication  or  catarrh.  It  is  rarely  neces- 
sary to  use  bismuth  and  never  necessary  to  use  opium  for  the  control  of  the 
diarrhea  in  acute  intestinal  indigestion  in  very  young  children.  The  gen- 
eral hygiene  of  the  nursery  should  be  carefully  looked  to.  The  infant  should 
have  all  the  fresh  air  it  can  get  without  unnecessary  exposure,  as  this  is  an 
important  factor  in  promoting  and  restoring  good  digestion. 

In  older  children  it  is  necessary  not  only  to  give  the  enema  and  the 
cathartic  and  to  insist  upon  abstinence  from  food,  but  it  is  very  commonly 
necessary  to  use  opium  for  the  relief  of  the  intestinal  pain.  This  may  be 
given  in  the  form  of  paregoric,  and  if  it  be  vomited  and  the  intestinal  colic 
be  severe,  a  small  dose  of  morphin  suitable  to  the  age  of  the  child  may  be 
given  hypodermically.  In  those  cases  where  opium  is  used  a  saline  cathar- 
tic is  preferable  to  the  castor  oil ;  sulphate  of  magnesia  will  act  quickly  and 
painlessly  in  clearing  the  intestinal  canal.  After  a  period  of  rest  to  the 
stomach  the  'child  may  be  given  broth,  toast,  malted  milk,  or  some  such 
simple  food  for  twelve  or  twenty-four  hours  and  then  gradually  return  to 
his  normal  diet.  During  the  attack  hot  applications  to  the  stomach  are 
indicated,  even  more  than  they  are  in  the  infant,  and  diastase  or  a  pepsin 
and  hydrochloric  acid  mixture  given  after  meals  may  hasten  convalescence. 


PATHOLOGY 


189 


CHAPTER  XXI 

ENTERIC    INFECTION 
(Enterocolitis) 

Enteric  infection  is  a  broad  term  covering  the  great  majority  of  the 
intestinal  disorders  of  infancy,  whose  etiology  and  preventive  treatment 
have  just  been  considered.  Under  this  condition  may  be  grouped  all  the 
intestinal  toxemias  and  intestinal  catarrhs. 

Pathology. — The  underlying  pathological  condition  is  an  infection  of  the 
intestinal  canal  with  microorganisms,  producing  abnormal  fermentations 


OAY 
OF  MONTH 

8 

9 

10 

11 

12 

13 

14 

OAY 
OF  DISEASE 

1 

2 

3 

4 

5 

6 

7 

107' 
106' 

105" 

Ll 

5     104° 

£5     103° 
a 

s 

LJ                o 

K     102 

t 

I    lor 

z 
u 

I      100' 

u. 

99° 

98° 
97° 

z 

s 

s 

i 

i 

i 

i 

s 

i 

i 

X 

i 

< 

i 

< 

i 

i 

< 

< 

f. 

i 

< 

^ 

J 

s 

z 

< 

Z 

<* 

: 

• 

1 

/I 

\ 

1 

' 

1 

V 

V 

^ 

\ 

i 

\ 

A 

\ 

^ 

[ 

y 

. 

J 

M 

V 

\ 

J 

'\ 

f" 

V 

'S 

V 

V 

/^ 

7 

Y 

Fig.  28. — Gastroenteric  Infection — Mild. 

of  its  food  contents,  which  result  in  the  formation  of  soluble  and  irritant 
poisons.  The  soluble  poisons  are  absorbed,  producing  a  more  or  less  severe 
systemic  intoxication.  The  irritant  poisons  produce  a  congestion  and  irri- 
tation of  the  intestinal  mucosa,  which  prepare  the  way  for  the  microorgan- 
isms to  produce  more  or  less  destructive  lesions  of  the  mucous  membrane. 
In  the  milder  cases  the  mucous  membrane  is  congested,  covered  with 
mucus,  and  shows  a  beginning  infiltration  with  round  cells  and  also  a  slight 
loss  of  superficial  epithelium.  Peyer's  patches  and  the  adjacent  nodes  are 
swollen.  As  the  disease  progresses  there  develops  a  catarrhal  inflammation 
of  the  mucous  membrane  of  the  intestine.  The  solitary  follicles  are  con- 
gested and  may  mark  the  site  of  small  necrotic  ulcers,  and  around  them 
superficial  iilcers  may  spread,  coalesce,  and  cover  a  large  portion  of  the  mu- 
cous membrane.     In  some  instances  this  process  is  more  necrotic,  the  solitary 


190 


ENTERIC    INFECTION 


follicles  breaking  down,  with  the  formation  of  deep,  ragged  ulcers.  These 
are  especially  located  in  the  colon.  The  mucous  membrane  of  the  colon 
and  lower  ileum  may  be  covered  with  a  grayish,  pseudo-membranous  exu- 
date. The  spleen  and  liver  may  be 
enlarged,  the  kidneys  may  show  degen- 
erative changes,  and  the  lungs  may  be 
congested  and  show  patches  of  bron- 
chopneumonia. 

Symptomatology.  — The  symptoms 
of  this  condition  fall  naturally  in  two 
groups,  namely,  those  resulting  from 
a  toxemia  produced  by  soluble  toxins, 
and  those  produced  by  the  intestinal 
irritation  and  resulting  intestinal  ca- 
tarrh. These  symptom  groups,  as  a 
rule,  are  inseparably  connected,  but  in 
most  cases  we  have  one  or  the  other  so 
predominating  that  one  has  little  dif- 
ficulty in  determining  whether  the 
toxemia  or  the  intestinal  catarrh  is, 
from  the  standpoint  of  immediate 
treatment,  more  important.  The  toxic 
sym]>tom6  are  commonly  more  pro- 
nounced at  the  onset,  and  later  the 
symptoms  of  intestinal  catarrh  or  en- 
terocolitis predominate.  But  through- 
out the  course  of  this  disease,  in  most 
instances,  the  toxic  and  catarrhal  symp- 
toms are  so  intermingled  that  they 
form  a  clinical  picture  which  prac- 
tically needs  not  be  further  subdivided 
into  syndromes. 

This  disease  is  commonly  marked 
by  fever,  nervous  symptoms,  vomiting, 
diarrhea,  and  more  or  less  prostration, 
and  it  may  vary  in  gravity  from  rap- 
idly fatal  cases  of  so-called  cholera  in- 
fantum, where  the  toxemia  is  so  vio- 
lent that  catarrhal  lesions  have  hardly 
time  to  develop,  to  mild  infections 
showing  but  slight  fever  and  nervous 
symptoms  accompanied  by  a  slight  diarrhea. 

The  fever,  which  is  one  of  the  earliest  symptoms,  varies  with  the  sever- 
ity of  the  infection ;  it  may  rise  within  the  first  twenty-four  hours  to  104° 
or  105°  F.  It  commonly  continues,  except  in  the  mildest  cases,  for  four  or 
five  days,  and  during  this  time  it  is  markedly  influenced  by  the  action  of 


r— 

~~~ 





r 

" 

■ 

'■« 

ft 

M'V  V 

• 

^ 

^ 

k 

n  tf  ^ 

^^ 

'nv  H 

■< 

~ 

>• 

n  d  ti 

s;:^ 

n  V  t( 

^ 

> 

H'v  tr 

W  d  S 

•^ 

n  V  « 

^  ■  1 

W  d  V 

B*?:^ 

'H 

V  8 

■;?• 

'If 

V  C 

,4 

n 

V  ? 

^ 

* 

^ 

R 

d  iT 

, 

If 

dO 

^ 

y 

•H 

d    S 

kjI 

'if 

dZ 

•t 

V   II 

Vs, 

'n 

V  8 

If 

V  C 

y^ 

■N 

V  Z 

/* 

■fC 

d  II 

> 

if 

If 

d  « 

jf 

'W 

^1 

If 

d  z 

ft>^ 

-R 

V  II 

Vw 

*n 

''/^ 

■R 

V  ■; 

yf 

If 

V  ?■ 

^0 

H 

ait 

/. 

' 

If 

J  B 

_, 

W  d  9 

-<, 

If  J  7. 

«L. 

^N^ 

R  V  II 

"" 

^ 

"*^s^ 

M  V  tl 

^^ 

nvc 

! 

^ 

If  V  7 

•<■ 

•H  JII 

,■. 

B  J« 

^ 

'N  d  « 

^ 

K  il 

s" 

■R'V  [I 

■A, 

'H'V  8 

•It  V  i; 

y 

> 

K  V  ?. 

/ 

4 

■RJ  M 

/y 

«  JS 

i/ 

" 

Hit 

r 

X. 

K  V  II 

^ 

'H'V  8 

"■*^ 

> 

n-w  <; 

H  V  J 

y-^ 

• 

R  d  II 

'* 

■>I<I» 

•Hd  t 

C""* 

H  d  Z 

^ 

BV  11 

Kv  e 

1  *' 

^ 

MVi; 

1 

■: 

n  V  I 

f 

•' 

Bd  11 

• 

■Bd« 

. 

' 

1^  ^' 

B  d  I 

vs^ 

II  V  II 

x^ 

s 

■Hy8 

5> 

■R  V  ? 

■RV  t 

•-^ 

Bd  11 

•i 

n  d  « 

y 

""-T* 

H 

■d  S 

*.•* 

d  I 

f    V  II 

, 

% 

u 

S 
P 

"s    °2    °2    S    s    g    S    ss    ^ 

3UniVU3dM31.    J.iaHN3UHVd 

o 


SYMPT0:MAT0L0GY  191 

cathartics.  As  the  intestine  is  unloaded  of  its  poisonous  contents  the  tem- 
perature falls  sharply,  perhaps  rising  again  to  he  again  lowered  hy  cathar- 
tic medication.  If  the  fever  continues  beyond  the  fifth  or  sixth  day  one 
may  conclude  that  catarrhal  lesions  in  the  intestine  have  formed,  and  the 
disease  from  this  time  on  presents  more  marked  symptoms  of  enterocolitis 
and,  in  favorable  cases,  less  marked  symptoms  of  toxemia.  The  persistence 
or  return  of  well-marked  toxic  symptoms  in  these  cases  is  a  very  unfavor- 
able indication. 

Vomiting  is  usually  the  symptom  which  calls  attention  to  the  child's 
illness.  It  occurs  in  a  large  percentage  of  the  cases  and  may  be  most  dis- 
tressing and  troublesome  during  the  first  twenty-four  or  forty-eight  hours. 
Within  this  time  under  appropriate  treatment  the  vomiting  disappears  and 
does  not  commonly  return,  but  when  it  dogs  return  it  is  an  unfavorable  in- 
dication, as  it  generally  means  an  increase  in  the  intestinal  toxemia.  The 
diarrhea  which  occurs  in  this  disease  is,  like  the  vomiting,  an  effort  on  the 
part  of  nature  to  get  rid  of  the  poisons  in  the  gastrointestinal  tract.  The 
earlier  the  diarrhea  appears  the  better  for  the  patient,  as  it  reduces  the 
fever  and  other  toxic  symptoms.  This  eliminative  diarrhea  usually  begins 
on  the  second  day.  The  fecal  discharges  vary  greatly  in  different  cases; 
they  are  commonly  foul  in  odor,  discharged  with  flatus,  green  in  color,  and 
contain  mucus  and  undigested  food.  The  number  of  discharges  may  vary 
with  their  size;  in  some  instances  being  small  and  frequent,  in  others 
copious  and  discharged  at  intervals  of  four  or  five  hours.  In  this  disease, 
above  all  others,  it  is  important  to  bear  in  mind  that  the  diarrhea,  espe- 
cially during  the  first  few  days,  is  a  life-saving  measure,  which  is  to  be 
encouraged  by  proper  medication.  If  constipation  be  present,  as  it  is  in 
some  cases,  then  the  vomiting  and  constitutional  symptoms  are  aggravated 
and  the  necessity  for  unloading  the  bowel  more  urgent.  As  the  catarrhal 
process  becomes  more  marked  in  the  colon  and  in  the  lower  ileum  the  in- 
testinal discharges  are  then  made  up  largely  of  bloody  mucus,  which  is 
passed  with  more  or  less  pain  and  straining  and  the  number  of  stools  may 
be  as  high  as  twenty  or  thirty  in  the  twenty-four  hours.  This  character  of 
stool  occurring  in  a  child  acutely  ill  and  having  an  elevation  of  temperature, 
whether  it  occurs  early  or  late  in  the  disease,  indicates  that  the  infection 
has  produced  an  enterocolitis.  It  should,  however,  be  noted  that  blood  in 
the  stools  does  not  always  mean  intestinal  ulceration ;  if  transitory  in  char- 
acter it  commonly  means  a  simple  catarrhal  process  with  marked  conges- 
tion. On  the  other  hand,  it  should  be  noted  that  marked  ulceration  may 
occur  without  blood  showing  in  the  stool  at  any  time.  The  diagnosis  of 
ulceration  of  the  bowels,  however,  may  be  assumed  if  the  fever  and  muco- 
purulent discharges,  tinged  or  not  with  blood,  continue  for  ten  days  or  two 
weeks.  Prolapse  of  the  rectum  is  not  uncommon  in  these  cases  and  in  rare 
instances  a  pseudo-membrane  may  be  seen  on  the  prolapsed  rectum.  Small 
pieces  of  pseudo-membrane  may  also  be  found  in  the  stool.  These  appear- 
ances are  the  only  positive  indications  of  the  presence  of  a  pseudo-mem- 
brane in  this  disease. 
14 


192  ENTEKIC    TXFECTION 

The  nervous  symptoms  are  most  important  and  their  severity  will  de- 
pend upon  the  virulence  and  amount  of  soluble  toxins  absorbed  from  the 
intestine,  and  upon  the  susceptibility  of  the  individual  infant  to  the  action 
of  these  poisons.  Restlessness,  fretfulness,  muscular  twitchings,  somno- 
lence, stupor,  convulsions,  delirium,  unconsciousness,  and  finally  paralysis 
of  vital  centers  resulting  in  death  may  occur.  In  severe  cases  a  peculiar 
nervous  syndrome  closely  resembling  meningitis  may  be  present.  Here  the 
stupor  and  convulsions  may  be  associated  with  retraction  of  the  head,  stif- 
fening of  the  muscles  of  the  neck,  irregular  pulse  and  respirations.  These 
symptoms  continuing  for  days,  with  fever  and  increasing  coma,  may  be 
distinguished  from  meningitis  by  the  fact  that  they  are  associated  with  the 
character  of  diarrhea  previously  described,  and  by  the  absence  of  charac- 
teristic findings  in  the  cerebrospinal  fluid  obtained  by  tapping  the  spinal 
canal.  Since  this  nervous  syndrome  is  not  associated  with  meningeal  le- 
sions it  is  perhaps  produced  by  the  action  of  toxins  on  the  nerve  centers. 
In  severe  cases  emaciation  is  extreme,  the  eyes  are  sunken,  the  fontanels 
depressed,  and  the  infant  may  die  from  exhaustion  or  pass  into  an  atrophic 
condition  from  which  it  requires  months,  if  not  years,  to  recover.  For- 
tunatel}',  however,  the  majority  of  the  cases  of  intestinal  infection  are  of 
moderate  severity  and  associated  with  a  mild  form  of  toxemia.  In  these 
cases  the  nervous  irritability,  muscular  twitchings,  mental  stupor  and  fever 
gradually  subside.  The  blood,  if  present,  disappears  from  the  stool,  but 
the  mucous  discharges  continue  with  more  or  less  tenesmus  for  six  or  seven 
days,  with  gradual  improvement  until  they  become  normal  at  the  end  of 
the  second  or  third  week. 

Urticaria,  erythema,  and  other  toxic  rashes  are  very  common,  especially 
in  the  milder  cases. 

The  general  appearance  of  the  infant  is  an  indication  difficult  to  de- 
scribe, but  one  that  impresses  the  physician  almost  more  than  any  other 
with  the  seriousness  of  this  disease.  The  character  of  the  prostration,  the 
facial  expression,  the  extent  of  the  emaciation  and  the  mental  alertness  of 
the  infant  vary  in  the  production  of  a  picture,  which  greatly  assists  the 
physician  in  making  his  prognosis  in  individual  cases. 

Cholera  infantum  represents  the  most  severe  type  of  acute  enteric 
infection.  It  has  no  distinguishing  characteristics  except  the  suddenness 
of  its  onset  and  the  severity  of  its  symptoms.  This  clinical  syndrome 
resembles  in  some  particulars  that  of  true  cholera,  and  it  has,  therefore, 
been  dignified  by  the  title  cholera  infantum.  It  usually  occurs  in  non- 
resisting  weaklings,  but  may  occur  in  normal  infants.  It  is  believed  to  be 
a  food  poisoning  commonly  produced  by  badly  contaminated  milk;  the 
infant  gets  such  a  large  initial  dose  of  toxins  that  it  is  almost  im- 
mediately overwhelmed  by  the  toxemia.  The  choleriform  diarrhea  pro- 
duces more  rapid  emaciation  and  loss  of  weight  than  any  other  dis- 
ease of  infancy.  The  stools  are  large,  frequent,  and  watery  in  char- 
acter and  this  violent  purging  is  accompanied  by  severe  vomiting., 
The  temperature   commonly   reaches    104°    or   105°    F.,    continues    high 


TREATMENT  193 

for  twelve  or  twenty-four  hours,  and  then  falls  with  the  collapse 
and  prostration  of  the  infant.  The  surface  temperature  is  cold,  while 
the  rectal  temperature,  in  the  rapidly  fatal  cases,  may  register  107°  F. 
Stupor,  convulsions,  and  coma,  following  each  other  in  rapid  succession, 
may  mark  the  progress  of  the  disease,  which  may  terminate  fatally  within 
twelve  hours,  but  which  commonly  lasts  for  three  or  four  days.  Under 
proper  treatment  some  of  these  cases,  especially  those  occurring  in  previ- 
ously normal  children,  may  recover. 

Prognosis. — Other  things  being  equal,  the  younger  the  infant  the  more 
unfavorable  the  prognosis.  The  prognosis  also  depends  upon  the  severity 
of  the  enteric  infection,  the  resistance  of  the  individual  infant,  the  hygienic 
surroundings,  and  the  character  of  the  treatment  instituted.  On  the  whole, 
however,  except  in  cholera  infantum,  the  prognosis  is  good,  since  the  vast 
majority  of  these  cases  are  produced  by  infections  so  mild  that  they  are 
readily  controlled  by  appropriate  treatment.  The  continuous  presence  of 
bloody  mucus  in  the  stools  for  weeks  indicates  ulceration  in  the  bowels, 
which  means  either  an  unfavorable  prognosis  or  a  very  slow  recovery. 

Treatment. — As  this  condition  in  the  beginning  is  essentially  an  acute 
intestinal  poisoning,  the  all-important  indication  (except  in  those  cases  of 
the  cholera-infantum  type)  is  to  cleanse  the  intestinal  canal  as  rapidly  as 
possible.  With  this  end  in  view  the  colon  should  be  irrigated  and  imme- 
diately thereafter  a  dose  of  castor-oil  or  sulphate  of  magnesia  given; 
the  oil  is  to  be  preferred  unless  the  stomach  be  very  irritable.  If 
the  oil  or  magnesia  is  rejected  by  the  stomach,  it  should  be  allowed 
to  rest  for  half  or  three-quarters  of  an  hour  and  then  washed  out 
with  a  solution  of  sodium  bicarbonate,  a  teaspoonful  to  the  quart.  Half  an 
hour  following  this  irrigation  calomel  should  be  administered,  one-quarter 
of  a  grain  combined  with  one  grain  of  sodium  bicarbonate,  every  half-hour, 
until  two  grains  have  been  given.  After  the  preliminary  cathartic  has 
cleared  the  intestinal  canal  there  is  commonly  no  further  vomiting  and  all 
the  toxic  symptoms,  including  the  fever,  are  much  modified  in  their 
severity,  but  in  the  event  that  the  vomiting  continues  to  be  a  troublesome 
symptom,  the  stomach  may  be  washed  out  with  normal  salt  solution  every 
six  to  twelve  hours  for  the  first  twenty-four  or  thirty-six  hours.  Luke- 
warm baths,  sponging  with  cool  water,  and  ice  caps  to  the  head  are  valuable 
measures  in  the  control  of  fever  and  nervous  symptoms  during  this  stage 
of  the  treatment. 

Diet. — It  is  evident  that  in  a  disease  where  the  unloading  and  cleansing 
of  the  intestinal  canal  are  of  such  vital  importance,  it  must  be  equally 
important  that  during  the  first  few  days  little  or  no  food  should  be 
given.  During  the  first  twenty-four  hours  only  water  should  be  given; 
during  the  second  twenty-four  hours  weak  tea  is  an  excellent  substitute 
for  food.  Alcohol  in  the  form  of  good  whiskey  or  brandy  may  also  be 
given  in  from  15-  to  30-drop  doses,  well  diluted,  every  three  or  four  hours, 
provided  the  stomach  is  in  a  condition  to  retain  it.  During  the  third 
twenty-four  hours,  if  the  infant  be  breast-fed,  it  may  be  allowed  to  nurse 


194  ENTERIC    INFECTIOlSr 

at  intervals  of  five  or  six  hours,  until  it  has  heen  demonstrated  that  the 
breast  milk  will  not  cause  a  return  of  the  symptoms,  and  within  the  next 
few  days  it  may  have  the  normal  quantity  of  breast  milk.  In  artificially 
fed  infants,  which  make  the  great  majority  of  the  cases,  the  infant  may 
on  the  third  day  be  given  barley  water,  toast  water,  or  a  weak  lamb  or  beef 
broth.  In  very  young  infants  the  barley  water  should  be  dextrinized,  as 
undigested  starch  is  not  easily  assimilated  at  this  age.  By  the  fourth  day, 
if  the  case  has  progressed  favorably  and  the  fever  and  other  toxic  symptoms 
have  subsided,  one  part  of  skimmed  milk  mixed  with  four  parts  of  dex- 
trinized barley  water  may  be  given.  If  this  agrees,  the  skimmed  milk  and 
beef  or  lamb  broth  may  gradually  be  increased  in  quantity  until  convales- 
cence is  thoroughly  established,  and  then  the  infant  should  be  gradually 
returned  to  its  original  diet.  In  more  severe  cases,  after  the  acute  symp- 
toms of  the  disease  have  been  controlled,  and  the  infant  still  has  unhealed 
ulcers  in  its  intestinal  canal  and  a  feeble  digestive  capacity,  the  skill  of  the 
physician  will  be  taxed  to  give  it  food  which  will  sustain  it  and  at  the  same 
time  will  not  cause  relapse.  Breast  milk  is  the  safest  and  best  of  all  foods 
to  accomplish  this  result.  If  a  wet-nurse  cannot  be  obtained  Finkelstein's 
albumin  milk,  or  the  curd  from  a  pint  of  cow's  milk  which  has  been  finely 
disintegrated  by  passing  it  through  a  sieve  two  or  three  times,  may  be 
added  to  a  pint  of  equal  parts  of  skimmed  milk  and  barley  water,  and  one 
or  the  other  of  these  foods  be  given  in  proper  quantities  until  the  symptoms 
of  intoxication  and  intestinal  irritation  have  subsided.  Fresh  buttermilk, 
and  the  buttermilk  and  malt  soup  formulas  elsewhere  described  are  useful 
in  some  cases. 

The  principles  of  importance  in  the  dietetic  management  of  these  cases 
are: 

First. — Starvation  for  a  variable  length  of  time,  depending  upon  the 
severity  of  the  case;  during  this  time  albumin  water  and  beef  juice,  so 
commonly  recommended,  are  not  to  be  given.  In  fact,  these  albuminous 
foods  are  especially  contraindicated  at  this  time,  and  continue  to  be  until 
the  putrefactive  processes  in  the  intestine  have  been  controlled. 

Second. — Breast  milk  is  by  far  the  best  food  in  these  cases,  but  early 
in  the  disease  it  should  be  given  in  small  quantities  and  at  long  intervals. 
If  artificial  food  must  be  used  it  should  be  poor  in  milk  and  cane  sugars  and 
whey  salts  and  rich  in  casein.  Weak  carbohydrates,  such  as  barley  water, 
dextrinized  gruels,  and  dextri-maltose  foods  may  be  used  to  dilute  the 
casein  mixtures.  These  foods  may  be  inoculated  with  lactic  acid  bacilli  so 
that  they  may  act  as  the  breast  milk  does  by  increasing  the  normal  intesti- 
nal flora,  which  antagonize  the  pathogenic  flora  which  have  taken  posses- 
sion of  the  intestinal  canal.     Fresh  buttermilk  acts  in  the  same  way. 

Third. — As  the  convalescence  of  the  infant  is  established,  the  food  is  to 
be  ver}^  gradually  increased  by  the  substitution  of  ordinary  milk  formulas. 
There  is  great  danger  of  reinfecting  the  intestinal  canal  by  overtaxing  it, 
especially  with  whole  milk,  lactose,  saccharose  and  whey  salts. 

Fourth. — In  more  severe  cases,  where  the  disease  is  prolonged  by  catar- 


TREATMENT  195 

rhal  or  ulcerative  processes  in  the  colon  and  lower  ileum,  the  dietetic  treat- 
ment is  much  more  prolonged  and  difficult,  and  a  wet-nurse  is  not  only 
advisable  but  absolutely  necessary  to  successful  convalescence.  If  a  satis- 
factory wet-nurse  cannot  be  obtained  then  a  very  slow  return  to  the  original 
diet  will  be  necessary,  and  this  period  may  extend  not  only  over  weeks  but 
over  months. 

Medicinal  Treatment. — Other  medical  treatment  than  that  above 
given  for  cleansing  the  intestinal  canal  may  be  of  value  in  individual  cases, 
but  it  should  not  interfere  with  the  preliminary  cathartic  medication  and 
should  not,  as  a  rule,  be  begun  until  the  second  or  third  day.  To  allay  the 
gastric  and  intestinal  irritation  3-  to  o-grain  doses  of  equal  parts  of  com- 
pound chalk  powder  and  guaiacol  carbonate  may  be  given  every  three  or 
four  hours,  and  a  day  or  two  later  for  the  relief  of  the  same  symptoms,  one 
may  substitute  for  the  above  prescription  1  or  2  grains  of  salol  and  3  to  6 
grains  of  subnitrate  of  bismuth  given  in  one-half-teaspoonful  doses  of 
simple  chalk  mixture.  If  the  diarrhea  persists  and  the  disease  becomes 
less  acute,  the  doses  of  bismuth  may  be  increased  to  10  grains  every  four 
hours.  Diastase  aids  the  digestion  of  carbohydrate  foods,  and  hydrochloric 
acid  and  pepsin,  taken  after  eating,  assist  in  the  digestion  of  milk  and 
other  protein  foods  and  are  of  value  during  convalescence. 

Morphin  in  1-50  to  1-100-grain  doses  is  a  remedy  of  great  value  for 
controlling  convulsions  where  simpler  measures  fail,  while  the  fact  should 
be  impressed  that  morphin  given  in  this  way  may  be  a  life-saving  meas- 
ure, yet  it  should  also  be  noted  that  the  practice  of  giving  morphin  for  the 
control  of  convulsive  disorders  may  be  abused  and  may  result  in  harm  to 
the  infant.  In  the  severe  cases,  however,  where  the  convulsions  are  con- 
tinuous, this  is  practically  the  only  remedy  that  can  be  relied  upon.  Holt 
recommends  1-50  grain  of  morphin  and  1-600  grain  of  atropin,  to  be  given 
hypodermically,  to  "neutralize  the  effect  of  poisons  on  the  heart  and  nervous 
system  in  cases  of  the  cholera  infantum  type."  This  use  of  morphin  is 
almost  the  only  indication  for  the  opium  preparations  in  the  treatment  of 
acute  gastroenteric  infections;  it  is  perhaps  never  necessary  to  give  opium 
to  infants  under  one  year  of  age  for  the  control  of  the  diarrhea  or  for  the 
relief  of  pain  or  other  intestinal  symptoms ;  the  indiscriminate  use  of  pare- 
goric and  other  opium  preparations  given  by  the  mouth  to  relieve  pain  and 
diarrhea,  increases  the  mortality  in  this  disease.  In  older  children,  after  the 
acute  symptoms  have  subsided,  the  opium  preparations,  especially  paregoric 
and  Dover's  powder,  may  be  of  value  in  relieving  the  pain  and  tenesmus 
which  occur  when  the  catarrhal  condition  becomes  localized  in  the  colon. 
But  even  in  these  cases  they  must  be  used  with  great  discrimination,  if  good 
rather  than  harm  is  to  result  from  their  use.  Colon  irrigations  are  of 
special  value  in  those  cases  which,  as  shown  by  the  large  quantities  of 
mucus  they  pass,  have  catarrh  or  ulceration  of  the  colon,  and,  as  the  object 
of  these  irrigations  is  largely  to  remove  the  mucus  and  otherwise  cleanse 
the  diseased  mucous  membrane  without  irritating  it,  there  can  be  little 
doubt  that  lukewarm  normal  salt  solution  will  serve  this  purpose  best. 


196  ENTERIC    INFECTION 

Irrigations  of  a  sufficient  amount  of  this  fluid  to  fill  the  colon  may  be  given 
from  one  to  three  times  in  twenty-four  hours.  If  the  infant  does  not  re- 
spond kindly  to  these  injections  or  shows  prostration  or  intestinal  irritation 
following  their  use,  they  may  be  discontinued.  Such  unfavorable  symp- 
toms, however,  are  more  commonly  due  to  faults  of  technique  than  to  the 
injections  themselves,  and  there  can  be  no  doubt  but  that  on  tbe  whole 
they  are  a  very  valuable  aid  in  the  treatment  of  this  disease.  In  the  event 
tliat  catarrh  or  ulceration  of  the  colon  continues  for  weeks  after  acute  con- 
stitutional symptoms  have  disappeared,  good  may  then  result  from  astrin- 
gent injections  of  alum  or  tannic  acid  (one  drachm  to  the  quart  of  water), 
following  the  cleansing  of  the  meml^rane  with  normal  salt  solution.  Castor- 
oil  is  the  cathartic  par  excellence,  not  only  in  the  beginning  but  through- 
out the  course  of  this  disease.  It  is  especially  valuable  in  those  cases  char- 
acterized by  the  passage  of  frequent,  small,  mucous  stools ;  not  only  in  these 
cases,  but  in  all  it  is  to  be  repeated  every  third  or  fourth  day  unless  it  be 
contraindicated  by  the  condition  of  the  stomach  or  some  idiosyncrasy  on 
the  part  of  the  child.  No  other  laxative  acts  so  kindly  in  carrying  off  the 
mucus  and  relieving  the  complicating  toxemia  as  does  castor-oil.  If  some 
other  laxative  must  be  used,  then  Eochelle  salts,  the  milk  or  sulphate  of 
magnesia  may  answer  the  purpose. 

Stimulating  Treatment. — Stimulating  treatment  by  hypodermic 
medication  may  be  a  life-saving  measure  in  very  severe  cases.  If,  for 
example,  during  the  first  few  days,  when  it  may  be  impossible  to  give  stimu- 
lants by  the  mouth,  the  infant  should  be  threatened  with  symptoms  of  col- 
lapse, hypodermic  stimulation  is  not  only  advisable  but  is  ofttimes  abso- 
lutely necessary.  The  most  valuable  stimulant  we  possess  is  normal  salt 
solution  (45  grains  of  sodium  chlorid  to  1  pint  of  sterile  water).  This 
should  be  given  by  hypodermoclysis,  6  to  8  ozs.  at  six-hour  intervals.  The 
salt  solution  is  rapidly  absorbed,  acts  as  a  general  stimulant,  furnishes 
fluid  to  the  body  media,  and  assists  in  the  elimination  through  the  kidneys 
of  the  absorbed  toxins  which  produce  such  a  profound  influence  upon  the 
nervous,  system.  Caffein  sodium  benzoate  in  14  to  %-grain  doses  may  be 
given  hypodermically.  Camphor  and  ether  are  valuable  stimulants  and 
may  be  used  as  directed  in  the  following  prescription  modified  from 
Forchheimer : 

IJ     CamphorsB   25  grs. 

Olei  amygdalae  erpress %  oz. 

M.     Five  to  ten  minims  hypodermically. 

]J     CamphoraB   25  .grs. 

^ther    2  drachms 

Olei  amygdalae  express 2  drachma 

M.     5  to  10  minims  hypodermically. 

The  above  hypodermic  medication  is  especially  valuable  in  the  treatment 
of  cases  of  cholera  infantum.  By  these  measures  the  life  of  the  infant  may 
sometimes  be  prolonged  until  the  vomiting  and  diarrhea  subside,  permit- 
ting the  administration  of  water  and  stimulants  by  the  mouth. 


CHRONIC    INTESTINAL    INDIGESTION    IN    INFANTS  197 

Hygienic  Treatment. — The  liygienic  treatment  of  these  cases  is  of 
the  utmost  importance.  While  acute  symptoms  threaten  the  life  of  the 
child  it  should  be  kept  at  home  and  there  jjlaced  under  the  most  favorable 
hygienic  conditions  possible.  Many  infants  are  rushed  away  from  their 
homes  when  acutely  ill  with  enterocolitis,  with  the  idea  that  cool,  pure 
country  air  is  of  more  importance  than  skilful  medical  attention  and  care- 
ful nursing  in  the  treatment  of  this  disease.  Many  such  infants  subjected 
to  long  railroad  journeys  die  on  the  road  or  soon  after  they  have  reached 
this  "ideal  climate,"  where  perhaps  they  have  not  found  good  medical  at- 
tention and  skilful  nursing.  Home  is  the  place  to  begin  the  treatment  of 
acute  enterocolitis  and  the  treatment  should  there  be  continued  until  the 
acute  symptoms  are  under  control  and  the  infant  is  in  a  condition  to  travel 
without  danger  of  a  relapse;  then  it  should  be  sent  for  its  convalescence 
to  some  bracing  climate  where  it  can  have  pure  cool  air. 


CHAPTER  XXII 

CHEONIC    INTESTINAL    INDIGESTION 

(Chronic  Enterocolitis^  Infantile  Atrophy,  Marasmus) 

CHRONIC    INTESTINAL   INDIGESTION   IN   INFANTS 

Etiology. — The  general  etiolog}'  of  this  condition  has  been  previously 
outlined;  here,  however,  certain  factors  prominent  in  the  chronic  forms  of 
intestinal  diseases  are  emphasized.  Age  is  an  important  predisposing  fac- 
tor; most  of  these  cases  occur  in  infancy,  but  they  are  not  uncommon  in 
the  child.  Among  predisposing  causes  the  following  may  be  noted :  Hered- 
ity, rickets,  anemia,  tuberculosis,  syphilis,  general  malnutrition,  and  previ- 
ous intestinal  attacks.  The  infant  may  inherit  from  weak  and  neurotic 
parents  a  physiological  incapacity  to  digest  ordinary  food.  The  heat  of 
summer,  impure  air,  and  dirty  surroundings  are  most  potent  factors  in 
producing  chronic  gastrointestinal  disturbances. 

The  exciting  causes  are  to  be  found  in  the  food.  If  the  disease  occurs 
in  breast-fed  babies  it  is  due  to  overfeeding,  too  frequent  feedings,  or  to 
some  fault  in  the  breast  milk.  Improper  artificial  feeding  is,  however,  the 
cause  in  the  vast  majority  of  cases.  Too  much  food,  in  ounces  given  at  a 
feeding  and  in  the  number  of  calories  in  twenty-four  hours,  overtaxes  the 
digestive  powers  of  the  infant  and  produces  repeated  attacks  of  acute  in- 
digestion and  intoxication,  which  in  time  so  diminish  its  normal  digestive 
capacity  that  it  is  in  a  more  or  less  constant  state  of  intestinal  indigestion. 
The  infant,  after  repeated  attacks  of  acute  intestinal  indigestion,  very  com- 
monly has  its  digestive  capacity  for  fat  and  whey  salts  very  much  low- 
ered. Wholesome  food,  therefore,  given  in  too  great  quantities  or  con- 
taining too  many  calories  or  given  at  irregular  intervals,  may,  after  a  time, 
produce  chronic  intestinal  indigestion,     Food  spoiled  by  bacterial  contami- 


198 


CIIHONIC    INTESTINAL   INDIGESTION 


nation  is  the  most  potent  cause  of  this  condition ;  it  acts  by  causing  repeated 
attacks  of  acute  intestinal  infection  which  in  time  produce  chronic  in- 
digestion. 

Pathology. —The  underlying  condition  is  a  pathological  digestive  in- 
capacity wliich  makes  it  impossible  for  the  infant  and  child  to  digest,  as- 
similate, or  metabolize  the  ordinary  food  suitable  to  its  age  and  weight. 
The  degree  of  this  incapacity  determines  the  seriousness  of  the  condition. 
In  many  cases  there  is  i)resent  a  low  grade  of  intestinal  catarrh,  so  that 
these  cases  might  properly  be  classed  as  chronic  enterocolitis.  But  from  a 
clinical  standpoint  this  differentiation  is  not  important  since  the  treatment 
is  the  same. 

Symptomatology. — Profound  increasing  malnutrition  associated  with  a 

chronic  diarrhea  is  the 
most  characteristic  symp- 
tom. The  number  of  dis- 
charges in  the  diarrheal 
cases  may  be  many  or 
few  in  a  day;  they  con- 
tain mucus,  curds  and 
undigested  food,  are  com- 
monly green  in  color, 
and  may  be  either  foul 
or  sour  in  odor;  they  are 
passed  with  flatulence, 
but  there  is  little  pain. 
The  buttocks  may  be  ir- 
ritated or  excoriated  from 
the  discharges.  The  stools 
usually  contain  neutral 
fats,  fatty  acids  and 
soaps,  and  the  curds  are 
commonly  small  and 
soft;  tough,  large,  casein 
curds  holding  in  their  meshes  large  quantities  of  fat  are  also  frequently  seen. 
Those  cases  in  which  the  diarrhea  is  a  marked  symptom  are  commonly  due 
to  an  incapacity  to  digest  sugars  and  fats.  In  other  cases  constipation  may 
be  a  marked  symptom  and  it  may  alternate  with  diarrhea.  In  the  con- 
stipated cases  the  stools  are  commonly  gray  or  white  in  color,  of  a  putty- 
like consistency,  covered  with  mucus,  and  have  a  foul  odor ;  there  is  usually 
more  or  less  fever,  colic,  and  nervous  symptoms.  No  hard  and  fast  lines 
can  be  drawn  separating  the  diarrheal  from  the  constipated  cases,  either  in 
their  symptomatology  or  their  etiolog}^,  since  in  the  same  infant  the  two 
symptom  groups  not  uncommonly  alternate ;  but  the  dry,  putty-like,  putrid, 
constipated  stool  is  commonly  associated  with  fat  indigestion,  and  the  co- 
pious, watery,  frequent,  diarrheal  stools,  sour  in  odor,  discharged  with  flatus 
and  irritating  to  the  buttocks,  are  usually  associated  with  sugar  indiges- 


FiG.  30. — Casein  Curds,  Actual  Size.     (Talbot.) 


CHRONIC    INTESTINAL    INDIGESTION    IN    INFANTS  199 


tion.  Protein  indigestion  may  be  associated  with  either  of  these  symptom 
groups.  Fever  is  commonly  absent;  subnormal  temperatures  are  common. 
Fever,  however,  associated  with  other  acute  symptoms,  is  an  indication 
that  an  intestinal  infection,  or  an  acute  intestinal  indigestion,  is  compli- 
cating the  chronic  process;  this  not  infrequently  occurs  during  the  pro- 
longed course  of  a  chronic  intestinal  indigestion.  Nervous  symptoms  are 
more  marked  in  the  constipated  cases.  The  appetite  is  usually  good,  the 
infant  very  commonly  empties  its  bottle  and  cries  for  more;  this  appetite 
far  beyond  its  digestive 
capacity  is  a  source  of 
great  trouble,  since  the 
mother  and  sympathetic 
relatives  are  led  to  be- 
lieve that  the  infant  is 
being  starved,  and,  as  its 
appearance  carries  out 
this  inference,  it  is  often 
difficult  to  feed  it  within 
the  range  of  its  digestive 
capacity.  The  urine  usu- 
ally contains  indican  or 
indolacetic  acid  and  ace- 
tone may  be  present. 

Infantile  Atrophy. 
— The  common  causes  of 
this  condition  are  pre- 
maturity, chronic  tuber- 
culosis, syphilis,  chronic 
intestinal  indiges- 
tion, chronic  enteroco- 
litis, improper  food, 
faulty  methods  of  feed- 
ing or  an  hereditary 
physiological  incapacity 
of  the  digestive  organs. 
It  is  largely  an  institu- 
tional disease,  occurring  especially  in  artificially  fed  children.  Wentworth 
believes  it  is  due  to  "a  defective  correlation  of  the  several  digestive  organs, 
stomach,  intestines,  pancreas  and  liver,"  which  results  in  disturbed  diges- 
tion and  feeble  assimilation  of  foodstuffs.  Edsal  has  demonstrated  the  ab- 
sence of  digestive  ferments  in  some  of  these  cases.  Finkelstein  and  other 
German  writers  believe  that  it  is  largely  due  to  an  inability  of  the  infant 
to  digest  and  assimilate  fat  (cream),  and  the  whey  salts. 

The  symptomatology  in  its  early  history  is  commonly  that  of  intestinal 
indigestion.  With  the  progress  of  this  disease  the  infant  loses  in  weight, 
becomes  anemic,  malnourished,  rachitic,  and  fiinally  profoundly  emaciated. 


Fig.  31. — Infantile  Atrophy. 


200  CHEONIC    INTESTINAL   INDIGESTION 

The  picture  presented  by  advanced  atrophy  is  truly  a  pitiful  one ;  the  face 
is  thin,  wistful,  senile,  the  eyes  are  sunken  in  their  sockets,  and  the  fon- 
tanels depressed;  the  neck,  arms,  and  legs  are  atrophied;  the  subcutaneous 
fatty  tissue  having  disappeared,  the  dry  skin  hangs  in  loose  folds  over  the 
bony  structures  and  a  general  edema  may  be  present.  The  abdomen  is  dis- 
tended and  tympanitic,  and  tlie  bones  of  the  chest  and  back  stand  out  promi- 
nently beneath  the  skin  which  enfolds  them.  In  these  advanced  cases  the 
stools  may  be  apparently  normal,  but  a  microscopical  examination,  as  a 
rule,  shows  undigested  food,  with  an  excess  of  neutral  fats,  fatty  acids  and 
soaps. 

Prognosis. — The  prognosis  of  intestinal  indigestion  depends  upon  the 
length  of  time  the  disease  has  lasted,  the  degree  of  malnutrition  it  has  pro- 
duced and,  above  all,  on  the  amount  of  injury  which  has  resulted  to  the 
infant's  digestive  and  assimilative  capacity.  In  severe  cases  which  have 
reached  the  stage  of  "atrophy"  the  prognosis  is  very  grave,  in  the  milder 
cases  there  is  a  fair  chance  of  recovery;  in  all  cases  the  convalescence  is 
slow,  and  success  largely  depends  upon  the  physician's  ability  to  impress 
upon  the  attendants  the  necessity  for  long-continued  attention  to  the 
minutest  details  in  the  care  and  feeding  of  the  infant. 

Treatment. — In  beginning  the  treatment  of  chronic  intestinal  in- 
digestion a  dose  of  castor-oil  should  be  followed  by  abstinence  from  food 
for  a  period  of  twelve  or  twenty-four  hours,  and  the  infant  should  tlien  be 
given  the  following  dietetic  treatment : 

Dietetic  Treatment, — In  the  beginning  the  mother  should  be  told 
that  the  object  of  the  dietetic  treatment  is  to  find  a  food  that  can  be 
digested  and  assimilated  in  small  quantities,  and  that  the  evidences  of  suc- 
cess in  treatment  will  be  manifested  by  the  improvement  in  and  gi-adual 
return  to  normal  of  the  intestinal  discharges  and  by  the  infant  beginning  to 
hold  its  own  in  weight,  but  that  under  no  conditions  is  it  expected  to  gain 
in  weight  for  some  weeks  to  come.  Such  an  understanding  is  necessary 
in  order  to  have  the  co-operation  of  the  mother  and  nurse  throughout 
the  long  and  tedious  treatment.  Human  breast  milk  is  the  most  valuable 
of  all  foods  in  the  treatment  of  these  cases  and  should,  therefore,  be  used 
when  it  can  be  obtained ;  it  is  absolutely  necessary  in  the  worst  cases,  those 
approaching  the  atrophic  type.  In  these  cases  of  infantile  atrophy  it 
may  be  necessary  to  resort  to  small  feedings  of  skimmed  breast  milk  to  give 
the  nutritional  processes  a  start,  and  then  continue  the  dietetic  treatment 
with  small  quantities  of  whole  breast  milk  nursed  from  the  breast  at  long 
intervals.  The  success  which  sometimes  follows  the  feeding  of  these  ap- 
parently hopeless  cases  of  atrophy  with  human  milk  depends  partly  on  the 
fact  that  it  contains  certain  ferments  which  assist  in  its  own  digestion,  and, 
since  the  fat  of  the  milk  is  the  most  potent  disturbing  factor  in  these 
cases,  the  fat-free  mother's  milk  is  the  ideal  food  with  which  to  begin  the 
feeding.  The  second  important  fact  to  be  remembered  is  that  whatever 
food  is  taken  it  must  in  the  beginning  be  given  in  very  small  quanitties, 
2  to  4  ounces  at  four-hour  intervals,  and  only  very  gradually  increased  when 


INTESTIXAL   IXDIGESTIOX    IX    OLDER    CHILDREX     201 

it  has  been  demonstrated  that  it  has  been  digested  and  assimilated.  Water 
may  be  given  in  the  intervals  between  the  feedings. 

When  breast  milk  is  not  available  the  infant  should  be  placed  upon  a 
fat-free  niilk,  ])eptonized  for  twenty  or  twenty-five  minutes,  and  then  placed 
on  ice  without  heating.  When  fed  it  should  be  diluted  one-half  with  boiled 
water,  to  which  lime  water  has  been  added.  iVfter  a  week  or  ten  days  a 
dextrinized  gruel  may  take  the  place  of  the  water  in  the  above  mixture. 
The  fat-free  peptonized  milk  and  dextrinized  gruel  mixture,  if  it  agrees 
with  the  infant,  should  be  gradually  adjusted,  in  ounces  given  at  a  feeding 
and  in  calories  given  in  twenty-four  hours,  to  suit  the  weight  of  the  indi- 
vidual infant.  After  some  weeks,  if  the  infant  is  progressing  favorably, 
small  quantities  of  fat  may  be  gradually  added  to  the  food.  This  is  best 
done  by  skimming  the  milk  a  little  less  closely.  Slowly  the  fat  is,  in  this 
way,  returned  to  the  food  formula  and  then,  perhaps  after  months  of  treat- 
ment, the  milk  is  slowly  dcpeptonized.  That  is  to  say,  the  peptonizing 
process  is  carried  on  for  a  shorter  time  and  with  less  peptonizing  powder 
until,  in  the  course  of  a  few  months,  it  is  discontinued. 

Finkelstein's  albumin  milk,  buttermilk,  and  malt  soup  formulas  are  of 
value  in  the  treatment  of  many  of  these  cases.  Beef  juice,  whey,  and  albu- 
min water  may  be  used  to  supplement  the  diet  when  other  foods  are  given  at 
long  intervals.  In  the  convalescence  from  this  condition  the  general  rules 
previously  outlined  under  Infant  Feeding  should  be  followed. 

Hygienic. — Fresh  air  and  a  suitable  climate  are  very  necessary  to  suc- 
cess. During  the  hot  summer  months  these  patients  should,  if  possible,  be 
sent  out  of  the  city  to  a  cool  country  place  in  the  north  or  to  the  mountains 
or  seashore,  where  they  may  live  out-of-doors.  These  delicate,  malnour- 
ished infants,  when  kept  out-of-doors,  often  require  artificial  heat  in  the 
form  of  hot-water  bottles  to  keep  their  bodies  and  extremities  warm.  They 
also  require  quiet  surroundings  so  that  they  may  have  all  the  undisturbed 
sleep  possible,  and  regular  bathing  for  its  Simulating  and  tonic  effects. 

Medicinal. — The  medical  treatment  is  of  secondary  importance.  When 
fever  or  nervous  symptoms  develop  a  laxative  such  as  castor-oil  or  milk  of 
magnesia  should  be  given  and  the  following  prescription  used : 

Ji     Misturae  cretse   |  i 

Liquid  taka-diastase    §  1 

Sig.  One-half  to  one  teaspoonful  with  each  feeding. 


CHRONIC  INTESTINAL  INDIGESTION  IN  OLDER  CHILDREN 

Etiology. — This  condition  is  exceedingly  common  and  is  frequentl}'^ 
overlooked,  being  mistaken  for  some  functional  nervous  disorder.  Its 
underlying  cause  is  usually  a  carbohydrate  intolerance;  it  is  aggravated 
and  prolonged  by  the  excessive  use  of  sugars  and  starchy  foods,  especially 
potatoes.  The  use  of  candies,  sweets  of  all  kinds  and  other  foods  unsuited 
to  the  child's  digestive  capacity  are  potent  factors.     Eating  between  meals 


202  CHRONIC    INTESTINAL   INDIGESTION 

and  at  irregular  intervals  will  aggravate  and  prolong  the  disease.  It  occurs 
very  commonly  between  the  ages  of  three  and  eight,  and  is  more  frequently 
seen  in  neurotic  cliildren  suffering  from  other  constitutional  diseases. 

Symptomatology. — These  children  are  neurotic,  malnourished,  thin, 
anemic,  and  delicate  in  appearance.  They  have  little  powers  of  resistance, 
and,  when  fatigued,  have  dark  circles  under  their  eyes.,  Their  appetites  are 
poor  and  capricious;  nausea,  vomiting  and  fever  may  occur  from  slight 
causes;  the  tongue  is  coated,  thick  and  flabby;  the  breath  at  times  has  an 
acetone  odor.  They  are  usually  constipated,  have  large  distended  abdo- 
mens, with  more  or  less  marked  tympanites.  The  intestinal  discharges  pro- 
duced by  laxatives  or  cnemata  consist  of  undigested  fecal  masses,  mixed 
with  mucus  and  fluid  matter  of  foul  odor.  The  stools  may  be  white  or  dark- 
brown  in  color,  with  a  coating  of  mucus  as  their  distinctive  characteristic. 
Following  a  cathartic,  such  as  castor-oil,  the  mucus  is  passed  in  large 
amounts.  The  urine  may  contain  acetone  or  diacetic  acid,  and  almost 
always  has  an  excess  of  indican  or  indolacetic  acid.  The  nervous  symptoms 
are  very  pronounced;  they  constitute,  in  fact,  the  S}Tiiptom  group  which 
calls  attention  to  the  child's  illness.  The  child  is  irritable,  fretful,  sleeps 
badly,  dreams  and  cries  out  in  its  sleep,  and  frequently  has  night-terrors. 
Fainting  spells,  asthma,  severe  headache  and  even  convulsions,  resembling 
epilepsy,  may  occur.  The  following  case  illustrates  a  severe  type  of  this 
condition. 

Boy,  age  five  years,  had  never  been  strong,  had  stomach  and  intestinal 
trouble  very  frequently  during  his  life,  was  thin,  anemic  and  malnourished. 
During  the  past  year  he  had  been  very  nervous.  This  nervousness  increased 
so  that  he  was  irritable,  cried  on  the  slightest  provocation,  was  very  restless 
at  night,  and  had  certain  peculiar  nervous  attacks.  These  attacks  came  on 
suddenly  with  dizziness,  the  boy  fell  to  the  ground,  his  mother  thought  that 
he  did  not  lose  consciousness,  was  sure  that  he  had  no  convulsive  move- 
ments, and  some  minutes  elapsed  before  he  was  able  to  regain  his  feet ;  they 
were  followed  immediately  by  severe  headache,  more  or  less  nausea,  and  a 
profound  sleep  which  lasted  some  hours.  From  this  sleep  he  awoke  quite 
as  well  as  before  the  attack.  Seven  of  these  attacks  occurred  during  the  past 
year,  and  they  increased  in  frequency  and  severity.  They  apparently  occu- 
pied the  border  line  between  migraine  and  epilepsy.  This  boy  suffered 
more  or  less  constantly  from  constipation,  abdominal  distention  and  flatu- 
lency. The  constipation  at  times,  however,  gave  way  to  an  attack  of  diar- 
rhea. He  had  no  fever,  and  his  mother  said  she  fed  him  almost  anything 
he  would  eat,  ''because  he  ate  so  little  that  it  could  not  hurt  him !"  The 
urine  was  highly  colored,  had  a  specific  gravity  of  1.023,  contained  no  albu- 
min, no  sugar,  but  there  was  a  marked  excess  of  indican.  This  boy  promptly 
recovered  under  treatment. 

Intestinal  indigestion  in  the  older  child  is  frequently  associated  with 
constipated,  mucous,  foul-smelling,  undigested  stools,  and  is  characterized 
by  intestinal  toxemia,  profound  nervous  symptoms,  great  excess  of  indican 
in  the  urine  and  progressive  failure  in  general  health.     These  cases,  not 


INTESTINAL   INDIGESTION    IN    OLDER    CHILDREN     203 

associated  with  diarrhea  and  intestinal  pain,  are  most  commonly  over- 
looked. 

Prognosis.' — This  is  good  under  proper  treatment.  The  disease,  how- 
ever, is  essentially  a  chronic  one,  and  it  should  be  understood  in  the  begin- 
ning that  it  will  require  many  months,  perhaps  years,  to  restore  the  child 
to  perfect  health. 

Treatment.  ^This  is  chiefly  dietetic.  It  is  most  important  that  the 
child  should  eat  suitable  food  at  proper  intervals,  taking  absolutely  no  food 
between  meals.  From  three  to  four  meals  a  day  should  be  prescribed,  de- 
pending upon  the  age  and  digestive  capacity  of  the  individual  child.  Food 
should  be  eaten  slowly,  well  masticated,  and  violent  exercise  directly  after 
eating  should  be  avoided.  The  following  foods  are  especially  contraindi- 
cated:  cakes,  candies,  sweets  of  all  kinds,  an  excess  of  starchy  foods, 
potatoes,  hot  breads,  fried  foods,  pastries,  and  raw  fruits.  In  some 
cases,  especially  those  in  which  the  stools  are  white  and  fragmentary, 
all  fats,  such  as  butter,  cream,  fat  meat  and  codliver  oil,  are  to  be  excluded 
from  the  diet.  The  following  foods  may,  as  a  rule,  be  recommended :  beef, 
lamb,  chicken,  fish,  eggs,  peptonized  milk,  skimmed  milk,  malted  milk,  beef 
juice,  broth,  toast,  a  small  quantity  of  bread,  and  certain  well-cooked  ce- 
reals, such  as  rice,  cream  of  wheat,  oatmeal,  farina,  arrowroot  and  tapioca. 
In  taking  these  cereals  as  little  sugar  as  possible  should  be  used,  and  they 
should  be  covered  with  milk  rather  than  with  cream.  As  the  child  con- 
valesces stewed  celery,  carrots,  asparagus  tips,  peas,  beans,  orange  juice, 
baked  apples,  and  prune  juice  may  be  allowed.  This  diet  should  be  perse- 
vered in  for  many  months,  and  above  all  sweets  and  potatoes  should  be 
excluded  until  convalescence  is  established. 

A  suitable  climate^  in  which  the  child  may  live  and  sleep  out  of  doors 
and  take  exercise  in  the  fresh  air,  will  greatly  hasten  convalescence. 

Medicines  play  a  useful  role  in  the  treatment  of  this  condition.  The 
careful  choice  of  laxatives  iS  important.  A  dose  of  castor-oil  is  occasionally 
necessary,  especially  when  acute  symptoms  develop.  It  is  most  important 
that  the  bowels  should  be  moved  daily.  This  may  be  accomplished  by  milk 
of  magnesia,  cascara,  or  at  times  by  saline  cnemata.  The  injection  at  bed- 
time of  one  to  three  ounces  of  olive  oil  into  the  rectum,  as  recommended  by 
Kerley,  is  very  valuable.  Systematic  massage  is  also  valuable  in  overcoming 
constipation.  Hydrochloric  acid  and  pepsin  taken  after  meals  are  of  value 
in  some  cases.  The  thick  malt  extracts  containing  diastase  are  especially 
useful  in  promoting  the  digestion  of  the  carbohydrates.  In  some  instances 
nux  vomica  and  the  organic  iron  preparations  may  be  combined  with  the 
malt  extracts,  to  the  advantage  of  the  patient.  With  the  judicious  use  of 
these  measures  chronic  intestinal  indigestion  in  the  older  child  can  be  suc- 
cessfully treated,  provided  the  physician  is  content  to  go  slowly  with  his 
dietetic  treatment,  and  provided  he  has  an  ever-watchful  mother  or  nurse 
to  see  that  the  details  are  carried  out. 


204    CONSTIPATION  AND  DILATATION   OF  THE   COLON 


CHAPTER  XXIII 

CHKONIC   CONSTIPATION    IN    INFANCY   AND    CONGENITAL 
DILATATION    OF    THE    COLON 

CHRONIC  CONSTIPATION  IN  INFANCY 

Etiology.— There  is  on  the  whole  a  natural  predisposition  to  constipa- 
tion in  infancy  which  is  in  part  counteracted  by  mother's  milk  and  is  aggra- 
vated, as  a  rule,  by  the  ordinary  modified  milk  formulas  used  in  artificial 
feeding.  This  predisposition  lies  largely  in  the  fact,  as  Jacobi  has  so  clearly 
pointed  out,  that  the  colon  is  relatively  longer  in  the  infant  than  it  is  in 
the  adult,  and  that  especially  the  sigmoid  flexure  runs  a  winding  con- 
voluted course  with  a  long  mesenteric  attachment.  This  condition  of  the 
colon  in  infancy  furnishes  a  suitable  reservoir  for  the  collection  and  reten- 
tion of  fecal  matter.  As  the  child  grows  older  and  its  body  increases  in 
size,  the  sigmoid  flexure  becomes  less  convoluted  and  gradually  approaches 
the  condition  found  in  the  adult. 

Rickets,  anemia,  and  especially  long-continued  intestinal  fermentation 
result  in  a  weakening  and  thinning  of  the  muscular  fibers  of  the  intestines, 
which  interfere  with  normal  peristalsis  and  lead  to  dilatation  of  both 
the  small  and  large  gut,  thus  producing  a  condition  of  muscular  atony, 
which  is  a  very  common  cause  of  constipation  in  infancy.  Heredity  may 
be  an  important  etiological  factor.  Constipation  is  not  infrequently  a 
family  disease.  Functional  incompetency  of  the  liver,  occurring  periodically, 
may  aggravate  a  mild  into  a  very  obstinate  constipation.  The  temporary 
absence  or  deficiency  of  bile  produces  dry,  putty-like,  putrid  movements, 
and  this  intestinal  condition  is  associated  with  lack  of  appetite,  coated 
tongue,  bad  odor  of  the  breath,  and  in  older  children  headache  and  nausea. 
Constipation  is  also  common  following  the  acute  infectious  diseases,  and 
especially  so  during  and  following  an  attack  of  meningitis.  Diseases  of 
the  rectum,  such  as  fissure  and  hemorrhoids,  may  produce  a  reflex  spasm 
of  the  sphincter  muscles  and  may  cause  the  child  to  resist  as  long  as  pos- 
sible the  desire  to  go  to  stool.  Simple  non-incarcerated  hernia  may  also  be 
a  cause.  Pyloric  stenosis  and  inflammatory  bands  produced  by  peritonitis 
may  cause  serious  forms  of  constipation.  The  frequent  use  of  purgative 
medicines,  especially  castor-oil,  may  be  a  factor  in  converting  a  simple  into 
a  chronic  constipation.  Irregularity  as  to  time  in  evacuating  the  bowels, 
which  results  from  lack  of  proper  training  of  infants  and  young  children, 
and  from  the  haste  of  older  children  to  go  to  school  in  the  morning  and 
their  confinement  during  school  hours,  is  a  cause  of  constipation. 

Dietetic  causes  are  more  important  than  all  other  factors  in  producing 
this  condition.  In  breast-fed  babies  constipation  most  commonly  results 
from  insufficient  food  and  from  a  low  percentage  of  fat  in  the  milk.  The 
mother's  milk  may  be  modified  to  overcome  this  condition  by  placing  her 


CHRONIC  CONSTIPATION  IN  INFANCY  205 

under  proper  hygienic  conditions  and  regulating  her  diet  according  to  the 
principles  elsewhere  outlined.  In  artificially  fed  infants  the  sterilization 
and  pasteurization  of  milk  and  the  giving  of  easily  digested  carbohydrate 
mixtures,  weak  in  fat  and  proteins,  are  common  causes  of  constipation.  In 
older  children  the  feeding  of  easily  digested  foods,  such  as  milk,  eggs,  meat, 
cereals,  white  bread,  toast  and  broths,  to  the  exclusion  of  fruits  and  veg- 
etables, is  a  potent  factor  in  producing  this  condition. 

Symptomatology. — Constipation  is  determined,  not  by  the  number  of 
stools,  but  by  the  character  of  the  discharges.  The  normal  infant  may  have 
from  one  to  four  soft  evacuations  in  the  twenty-four  hours,  but  when  con- 
stipated the  stools  are  composed  of  hard,  dry,  round  or  fragmentary  fecal 
masses  passed  with  difficulty  and  with  more  or  less  straining  and  tenesmus. 
These  discharges  may  occur  two  or  three  times  in  the  twenty-four  hours 
or  an  interval  of  days  may  elapse  between  them.  The  fecal  masses  may 
also  be  covered  with  mucus  and  stained  with  blood.  The  infant  loses  its 
appetite,  is  restless,  sleepless,  nervous  and  irritable;  it  has  attacks  of  colic 
with  abdominal  distention ;  it  may  suffer  from  frequent  attacks  of  intestinal 
indigestion  with  vomiting,  fever  and  severe  nervous  symptoms,  even  con- 
vulsions. This  latter  symptom  group  is  due  to  the  intestinal  toxemias  pro- 
duced by  the  constipation  and  occurs  especially  in  rachitic,  malnourished 
infants.  In  these  cases  an  increase  in  the  indican  in  the  urine  may  be  a 
valuable  indication  of  the  onset  of  an  intestinal  toxemia. 

In  older  children  an  excess  of  indican  or  indolacetic  acid  in  the  urine  is 
a  more  valuable  indication  of  the  extent  of  the  putrefaction  going  on  in  the 
intestine.  The  intestinal  toxemia  which  results  from  the  constipation  is 
not  infrequently  the  cause  of  a  more  or  less  profound  malnutrition  and 
anemia,  especially  of  the  chlorotic  type.  These  children  may  also  suffer 
not  only  from  colic  and  indigestion,  but  frequently  from  obscure  nervous 
symptoms  such  as  headache  of  the  migrainous  type  and  attacks  of  "recur- 
rent vomiting."  Vertigo  and  temporary  loss  of  consciousness  may  form  the 
nucleus  of  a  symptom  group,  which  may  ultimately  develop  into  epilepsy  if 
the  constipation  and  resulting  intestinal  toxemia  are  not  relieved. 

In  both  infants  and  older  children  fissure  and  prolapse  of  the  rectum, 
and  hemorrhoids  may  result  from  chronic  constipation  and  may  then  aggra- 
vate the  condition. 

Diagnosis. — The  diagnosis  of  constipation,  as  the  all-important  cause 
of  "a  severe  nervous  syndrome  or  of  a  profound  anemia,  may  sometimes  be 
overlooked,  especially  in  older  children.  It  is  therefore  important  for  the 
physician  to  keep  in  mind  the  fact  that  such  severe  symptom  groups  may 
have  their  origin  solely  in  a  chronic  constipation.  A  careful  examination  of 
the  abdomen  may  reveal  in  these  cases  impacted  fecal  masses  in  the  colon. 
This  examination  should  never  be  omitted  in  any  case  of  constipation,  how- 
ever mild  it  may  appear.  It  is  also  important  before  beginning  the  treat- 
ment that  the  cause  of  the  constipation  should  be  made  out.  The  family 
history  as  to  heredity  should  be  carefully  noted.  The  rectum  should  be 
examined  for  local  disease  and  the  genitalia  for  sources  of  reflex  irritation; 


S06    CONSTIPATION  AND  DILATATION   OF  THE   COLON 

l)liyiiiosis  is  of  special  importance.  These  abnormalities  about  the  rectum 
anil  genitourinary  organs  may  locate  the  cause  of  the  constipation.  The 
form  of  constipation  wliich  occasionally  results  from  an  excess  of  cream  in 
the  infant's  food  should  also  be  kept  in  mind ;  in  this  condition  the  stools 
are  gray,  dry,  fragmentary  and  putrid.  It  is  also  most  important  to  de- 
termine whether  an  atonic  condition  of  the  intestine  is  the  cause  of  the 
constipation ;  in  these  cases  the  abdomen  is  distended  with  gas,  the  infant 
is  anemic  or  rachitic,  and  enemata  are  not  effective  in  unloading  the  bowels ; 
an  active  cathartic,  however,  with  temporary  abstinence  from  food  relieves 
the  distended  intestine  and  flattens  out  the  abdomen. 

Treatment. — Treatment  in  Infancy. — It  should  be  understood  in  the 
beginning  that  constipation,  especially  in  the  artificially  fed  infant,  is  so 
common  that  one  may  almost  consider  it  the  normal  condition,  and  it  should 
also  be  understood  that  this  mild  form  of  constipation  occurring  in  infants 
under  one  year  of  age  cannot,  as  a  rule,  be  altogether  cured  by  diet.  It 
must  therefore  be  relieved  by  the  introduction  into  the  rectum  of  an  oiled 
catheter  or  a  gluten  suppository,  or  a  small  quantity  of  normal  salt  solution 
or  olive  oil.  At  this  age  glycerin  and  soap  suppositories  should  not  be 
habitually  used,  as  they  may  produce  local  disease  of  the  rectum  and  thus 
aggravate  and  complicate  the  constipation.  Medicines  are  also  of  value, 
especially  the  milk  of  magnesia,  which  may  be  used  occasionally  to  supple- 
ment the  local  measures  above  described.  Castor-oil  is  contraindicated  un- 
less an  intestinal  intoxication  with  fever  and  constitutional  symptoms 
complicate  the  constipation.  Diseases  of  the  anus  and  rectum  should  be 
relieved  by  appropriate  treatment. 

The  dietetic  treatment  is  important.  Eaw,  clean  milk  should  be  sub- 
stituted for  sterilized  milk;  where  this  is  not  possible  pasteurized  milk 
should  be  used.  Oatmeal  water,  or  dextrinized  gruels  may  be  used  as  a 
diluent  for  the  milk;  any  time  after  the  sixth  month  orange  juice 
may  be  given  to  the  normal  infant,  beginning  with  the  juice  of  half 
an  orange  once  in  twenty-four  hours.  The  use  of  cream  mixtures,  which 
has  been  so  widely  recommended,  is  attended  with  some  danger;  there  can 
be  no  doubt,  however,  but  that,  in  infants  having  a  normal  digestive  ca- 
pacity for  fats,  cream,  provided  it  is  clean  and  wholesome,  may  be  added 
to  advantage  in  small  quantities  to  the  milk  formula.  An  infant  under  six 
months  of  age  should,  however,  not  exceed  3  per  cent,  of  fat  and  in  older 
infants  the  fat  percentage  should  not  go  above  4  per  cent.  The  thick  malt 
extracts,  such  as  maltine,  maltzyme  and  Trommer's  malt,  are  much  more 
valuable  in  the  treatment  of  constipation  in  infancy  than  cream,  and  they 
are  not  attended  with  any  danger.  They  may  be  given  in  the  nursing 
bottle;  for  infants  three  months  of  age  one  and  a  half  teaspoonfuls,  and 
at  one  year  of  age  four  teaspoonfuls  in  the  twenty-four  hours.  With  this 
treatment  it  is  commonly  possible  to  control  constipation  during  the  first 
year  of  life,  but  it  should  ever  be  kept  in  mind  that  if  constipation  at  this 
age  cannot  be  relieved  by  simple  means  it  is  better  to  temporize,  awaiting 
the  time  when  the  infant  is  able  to  take  other  foods  for  a  permanent  cure 


CHRONIC  CONSTIPATION  IN  INFANCY  207 

of  the  condition.  Many  vigorous,  healthy  infants  have  been  made  ill  by 
strong  medicines  or  by  feeding  cream  in  too  large  quantities  or  by  using 
other  foods  beyond  the  digestive  capacity  of  the  infant. 

Treatment  During  the  Second  Year. — Dietetic. — All  the  measures 
above  noted  may  apply  in  the  treatment  of  constipation  during  the  second 
year.  Orange  juice  may  be  used  in  larger  quantities,  cream  may  be  given 
with  less  danger,  and  cooked  fruits,  such  as  apple  sauce  made  from  ripe 
apples,  and  prune  juice,  may  be  allowed.  Wliole  wlieat  bread,  well  buttered, 
may  be  added  to  the  diet  and  in  the  latter  part  of  the  year  fresh,  well- 
cooked  green  vegetables  may  be  given. 

In  older  children  raw  and  stewed  fruits  suited  to  the  age  and  digestive 
capacity  of  the  child  should  be  prescribed.  Bran  biscuits,  whole  wheat 
flour,  unstrained  oatmeal  with  butter  and  cream  and  a  liberal  supply  of 
fresh  vegetables  should  form  part  of  the  diet,  and  the  child  should  be  in- 
duced to  take  large  quantities  of  water  between  meals.  Abdominal  massage 
is  of  great  value,  especially  in  older  children ;  it  should  be  of  such  a  char- 
acter that  it  will  give  tone  to  the  abdominal  muscles,  stimulate  peristalsis 
and  facilitate  the  emptying  of  the  colon  and  sigmoid  flexure.  An  active 
outdoor  life  or  gymnastic  exercises  under  a  satisfactory  tutor  should  be  in- 
sisted upon.  In  obstinate  cases  Kerley  recommends  the  introduction  of 
four  to  six  ounces  of  warm  olive  oil  at  bedtime;  the  oil  is  to  be  introduced 
high  up  into  the  sigmoid  flexure  and  is  to  be  retained  during  the  night; 
if  necessary  a  napkin  can  be  used  to  prevent  the  child  from  soiling  the  bed. 

Medical  Treatment. — Olive  oil  or  codliver  oil,  combined  with  one  of 
the  thick  malt  extracts,  may  be  used  to  great  advantage,  especially  after 
the  first  year  of  life.  Calomel  and  sodium  phosphate  may  occasionally 
be  necessary  for  the  relief  of  acute  conditions  which  may  arise.  The  so- 
dium phosphate  is  especially  valuable  in  children  oyer  two  years  of  age 
with  a  gouty  or  bilious  diathesis,  suffering  from  hereditary  constipation. 
In  these  cases  a  saturated  solution  of  phosphate  of  soda  may  be  given  in 
milk.  Sulphate  of  magnesia  and  Rochelle  salts,  like  castor  oil  and  rhubarb, 
are  of  value  only  in  beginning  the  treatment  of  aggravated  cases  or  for 
relieving  acute  intestinal  symptoms  which  may  develop  during  the  treat- 
ment. Cascara  is  the  cathartic  of  greatest  value  in  the  treatment  of  con- 
stipation in  older  children;  the  aromatic  cascaras  on  the  market  are,  for 
the  most  part,  reliable;  they  should  always  be  given  at  bedtime  and  an 
effort  should  be  made,  as  time  goes  on  and  other  treatment  is  instituted, 
to  gradually  reduce  the  dose.  In  carrying  out  this  treatment  the  child 
should  be  made  to  use  the  chamber  at  a  regular  time  every  morning,  and  if 
at  the  expiration  of  fifteen  minutes  a  satisfactory  evacuation  has  not  re- 
sulted a  gluten  suppository  or  a  small  salt  water  injection  should  be  given. 
In  this  way  the  habit  of  going  to  stool  at  a  regular  hour  will  be  established 
and  this  will  do  much  to  complete  the  cure  of  the  constipation.  The  habit 
of  regular  evacuations  at  regular  hours  should  be  begun  in  early  infancy; 
it  may  sometimes  be  accomplished  when  the  child  is  six  months  of  age,  but 
from  the  end  of  the  first  year  it  should  be  an  important  part  of  the  routine 
15 


208    COXSTIPATIOX   AND   DILATATION   OF   THE   COLON 

treatment  and  should  be  insisted  upon  long  after  the  constipation  has  been 
cured.  In  connection  with  this  method  of  training  and  the  use  of  cascara, 
nux  vomica  or  strychnin  may  be  employed;  4  drops  ol'  luix  vomica  or  1/100 
grain  of  sulpliate  of  strychnin,  given  three  times  a  day  before  meals,  is  a 
suitable  dose  for  a  child  six  years  of  age.  These  drugs,  if  dissolved  in 
equal  parts  of  sherry  wine  or  essence  of  pepsin,  are  not  unpalatable. 

B     Strychnin  sulph ^  S^- 

Sherry  wine 2  ozs. 

Ess.  pepsin   2  ozs. 

Sig.  Teaspoonful  before  eating  for  child  six  years  of  age. 

This  prescription  may  be  continued  for  many  weeks,  and  in  the  mean- 
time the  cascara,  which  is  being  given  in  very  accurate  and  just  sufficient 
doses  to  produce  a  normal  evacuation,  is  gradually  diminished. 


CONGENITAL  DILATATION  OF  THE  COLON 

Etiology. — Congenital  dilatation  of  the  colon  is  a  rare  disease  which 
may  manifest  itself  in  two  rather  distinct  clinical  types. 

First,  the  condition  described  by  Hirschprung  in  1880.  It  has  its 
origin  in  a  congenital  malformation  of  the  colon  which  manifests  itself 
by  clinical  phenomena  directly  after  birth.  The  colon  is  elongated,  con- 
voluted and  much  dilated  and  its  walls  are  commonly  hypertrophied.  This 
condition  leads  to  the  accumulation  and  retention  of  the  meconium  and 
other  fecal  matter  and  to  a  subsequent  gaseous  fermentation,  which  results 
in  distending  and  further  dilating  the  colon.  From  time  to  time  during  the 
progress  of  this  disease  bacteria  may  cause  putrefactive  processes  which 
may  result  in  a  general  systemic  intoxication. 

The  symptom  group  in  these  cases  is  very  characteristic.  The  infant 
at  birth  may  not  appear  abnormal,  since  its  intestinal  canal  is  free  from 
bacteria  and  fermentative  processes,  but  as  soon  as  it  commences  to  take 
food  abdominal  distention  appears  and  the  attendants  note  the  fact  that 
the  bowels  have  not  been  evacuated.  Eectal  injections  may  cause  the  dis- 
charge of  gas  and  small  quantities  of  fecal  matter.  The  escape  of  gas  flat- 
tens the  intestine,  but  the  dilatation  of  the  abdomen  very  shortly  returns 
as  a  result  of  the  gaseous  fermentation  going  on  in  the  colon.  The  infant 
fails  to  thrive  and,  as  a  rule,  continues  to  grow  weaker,  since  in  these  cases 
it  is  practically  impossible  to  keep  the  colon  evacuated  and  control  the 
fermentative  processes.  As  time  goes  on,  if  the  infant  lives,  the  distention 
of  the  colon  becomes  so  great  that  it  may  be  outlined  against  the  enormously 
distended  abdomen,  and  the  fecal  masses,  removed  by  cathartics  and  ene- 
mata,  are  covered  with  mucus  and  have  a  putrid  odor.  Sooner  or  later — 
it  may  be  weeks  and  it  may  be  many  months — ^the  infant  gradually  suc- 
cumbs from  inanition  or  intestinal  intoxication.  The  latter  may  produce 
stupor,  coma  and  convulsions. 


CONGENITAL  DILATATION    OF   THE   COLON  309 

The  second  group  of  cases  also  has  its  origin  in  a  congenital  malforma- 
tion of  the  colon,  which  is  apparently  a  great  exaggeration  of  the  physi- 
ological condition  found  in  infancy,  namely,  the  long-convoluted,  freely 
movable  sigmoid  flexure  and  descending  colon.  The  fecal  material  accumu- 
lates in  this  reservoir  and  undergoes  a  gaseous  fermentation,  and  later 
putrefactive  processes  may  cause  intestinal  toxemia  and  start  catarrhal 
processes  in  the  mucous  membrane  of  the  cecum,  which  may  end  in  ulcera- 
tion and  abscess.  The  differentiation  of  the  two  types  of  congenital  dila- 
tation of  the  colon  lies  largely  in  their  symptomatology  and  the  time  in  the 
life  of  the  infant  when  the  first  symptoms  are  made  manifest. 

Symptomatology. ^An  infant,  that  has  not  perhaps  thrived  well  from 
birth,  at  the  end  of  the  third  or  fourth  month  of  life  develops  a  very  marked 
constipation  associated  with  abdominal  distention.  As  time  goes  on  the 
constipation  becomes  more  aggravated  and  the  colonic  distention  becomes 
greater,  so  that  the  syndrome  produced  gradually  comes  to  resemble  that 
of  the  first  group  of  cases  which  occurs  directly  after  birth.  This  second 
group  of  cases,  however,  occurring  in  older  infants,  is  not  so  severe  in  its 
onset  and  not  quite  so  serious  in  its  nature.  The  enormous  dilatation  of 
the  colon,  which  in  time  results,  is  not  altogether  congenital,  but  is  for  the 
most  part  brought  about  by  fermentative  processes  in  the  sigmoid  flexure. 
Gradually  the  colon  becomes  so  enormously  dilated  that  it  distends  the 
abdomen  to  such  an  extent  as  to  interfere  with  the  action  of  the  diaphragm, 
even  producing  dyspnea  and  cyanosis.  As  the  disease  progresses  it  be- 
comes a  more  and  more  difficult  matter  to  unload  the  colon,  and  the  fecal 
matter  discharged  contains  more  mucus  and  is  more  putrid.  The  intestinal 
toxemia  and  inanition  present  in  these  cases  materially  assist  in  producing 
the  emaciation,  the  progressive  anemia,  asthenia  and  the  severe  nervous 
symptoms,  such  as  coma  and  convulsions,  which  may  mark  the  downward 
progress  of  the  disease.  A  most  satisfactory  demonstration  of  the  enlarged 
colon  can  be  made  by  X-ray  pictures,  after  giving  large  doses  of  subnitrate 
of  bismuth;  by  this  method  the  size  and  position  of  the  colon  can  be 
made  out. 

Prognosis. — The  prognosis  is  bad,  only  about  10  per  cent,  of  the  cases 
reported  have  recovered.  The  disease  may  be  prolonged  for  a  number  of 
years ;  the  majority  of  cases,  however,  die  before  the  end  of  the  second  year, 
but  some  of  the  milder  ones  assume  a  chronic  form  and  may  live  for  eight 
or  ten  years.    The  prognosis  in  the  chronic  cases  is  slightly  more  favorable. 

Treatment. — The  medical  treatment  is  very  unsatisfactory.  The  prime 
object  is  to  sustain  and  nourish  the  child,  if  this  be  possible,  by  giving  it 
the  foods  most  suitable  to  its  age  and  condition.  In  the  acute  cases  oc- 
curring just  after  birth,  or  within  a  few  months  thereafter,  breast  milk  is 
the  only  food  to  be  considered.  If  the  infant  live,  however,  longer  than 
one  year  the  dietetic  treatment  is  to  be  the  same  as  that  outlined  under 
Chronic  Indigestion.  The  next  indication  is  to  relieve  the  gaseous  disten- 
tion of  the  colon  by  the  introduction  of  a  rectal  tube  and  to  keep  the  bowels 
open  and  the  colon  as  well  washed  out  as  possible  by  mild  laxative  medica- 


210  INTESTINAL   PARASITES 

tion  and  by  enemata.  In  early  infancy  the  most  appropriate  laxative  is 
the  milk  of  magnesia.  In  the  milder  and  more  chronic  cases  that  live  to  be 
over  two  years  of  age  the  cascara  preparations  are  more  appropriate.  The 
daily  use  of  salt  water  enemata,  for  the  purpose  of  unloading  and  cleansing 
the  colon,  is  necessary  throughout  the  course  of  the  disease.  In  addition 
to  these  measures  the  chronic  cases  may  be  benefited  by  massage  and  elec- 
tricity. The  massage  should  begin  at  the  cecum  and  end  at  the  sigmoid 
flexure,  its  object  being  to  unload  the  colon  and  to  give  tone  to  its  muscular 
coats.  Faradization  of  the  large  intestine  has  also  been  recommended;  in 
applying  electricity  both  electrodes  may  follow  the  course  of  the  large  in- 
testine as  outlined  through  the  abdominal  wall,  or  one  may  be  inserted 
into  the  rectum  and  the  other  be  applied  to  the  abdomen  over  the  course 
of  the  large  intestine.  Tincture  of  nux  vomica  or  strychnin  may  be  used 
as  a  tonic  in  association  with  the  cascara  preparations  as  directed  under 
the  treatment  of  chronic  constipation.  The  permanent  cure  of  these  cases, 
however,  can  be  hoped  for  only  by  operative  measures;  they  may  be 
greatly  benefited  by  the  establishment  of  an  artificial  anus  above  the  point 
of  greatest  colonic  distention.  This  surgical  procedure,  by  largely  putting 
out  of  function  the  diseased  portion  of  the  colon,  enables  it  to  partially  re- 
cover its  tone,  and  the  subsequent  final  cure  of  these  cases  is  to  be  hoped 
for  in  the  closure  of  the  artificial  anus  and  turning  the  fecal  stream  again 
into  the  colon,  which  rest,  massage  and  electricity  have  placed  in  a  more 
normal  condition.  Resection  of  the  diseased  portion  of  the  colon  itself  may 
be  made;  this  operation,  however,  has  not  been  tried  often  enough  to  de- 
termine its  ultimate  value. 


CHAPTER  XXIV 
INTESTINAL   PARASITES 

Within  the  last  fifty  years  in  this  country,  worms  have,  both  to  the  lay 
and  the  medical  mind,  been  losing  their  importance  as  pathological  factors. 
This  is  largely  due  to  two  reasons.  First,  with  an  advancing  civilization 
there  has  come  a  higher  average  of  personal  and  household  cleanliness  and 
more  sanitary  methods  of  disposing  of  fecal  matter;  these  improvements 
in  the  hygienic  surroundings  of  children  have  actually  diminished  the  per- 
centage of  cases.  Second,  with  an  advancing  knowledge  of  diseases  of  chil- 
dren physicians  have  learned  that  the  vast  majority  of  symptom  groups, 
which  were  formerly  thought  to  be  due  to  worms,  can  now  be  associated 
with  other  definite  pathological  conditions,  and  that,  with  the  exception  of 
the  hook-worm,  these  intestinal  parasites  rarely  cause  serious  or  pronounced 
constitutional  symptoms. 


INTESTINAL    CESTODES 


211 


INTESTINAL  CESTODES 

{TenioB,  Tapeworms) 

Varieties.- — The  following  varieties  of  tapeworm  are  found  frequently 
enough  in  children  to  deserve  stud}' :  the  tenia  saginata,  the  tenia  solium,  the 
tenia  elliptica,  the  hymenolepis  nana,  and  the  bothriocephalus  latus. 

Tenia  Saginata. — The  tenia  saginata,  or  beef  tapeworm,  is  the  form 
most  commonly  seen  in  this  country.  This  worm  may  be  over  twenty  feet 
in  length,  beginning  with  a  small  square  head,  2  to  3  mm.  thick,  at  the 
corners  of  which  are  suckers  containing  circles  of  pigment.  With  these 
suckers,  which  are  very  powerful,  the  worm  fastens  itself  to  the  mucous 
membrane  of  the  intestine.  Behind  the  head  is  a  still  thinner  neck,  which 
gradually  widens  out,  presenting  a  tape-like  appearance.  The  body  of  this 
tapeworm  is  divided  into  segments,  which  when  sexually  mature  are  ap- 
proximately 18  mm.  long  and  7  mm.  broad.  Each  matured  segment  is 
filled  with  a  uterus,  having  a  central  canal  with  branches  like  a  tree  ex- 
tending in  every  direction.  These  uteri  when  filled  with  eggs  are  very 
easily  discerned,  but  in  the  mature  segments  which  have  been  broken  off 
from  the  worm  and  been  discharged  the  eggs  are  not  very  plentiful.  The 
eggs  are  oval  or  round,  have  a  brownish-yellow  color,  but  no  very  distinctive 
individual  characteristics.  Infection  occurs  from  eating  beef  containing 
this  parasite.  The  life  C3'cle  of  this  tapeworm,  as  of  all  others,  passes 
through  three  stages — the  egg,  the  embryo  and  the  worm.  The  eggs  are 
passed  with,  the  segments  from  the  intestinal  canal  of  the  human  being 
and  contaminate  the  pastures  .or  other  food  material  of  cattle.  The  cattle 
taking  these  eggs  into  their  intestinal  canals,  they  are 
there  developed  into  the  embryo.  This  embryo, 
which  contains  the  fully  developed-  head  of  the 
tapeworm,  escapes  through  the  intestinal  wall  and 
lodges  in  the  muscles  and  other  tissues  of  the  animal 
and  there  becomes  encysted,  producing  a  cysticercus. 
Cattle  thus  infected  and  their  moat  also  are  said  to 
be  "measly."  This  "measly"  beef  containing  the 
embryos,  if  taken  in  a  raw  or  imperfectly  cooked 
state,  passes  into  the  intestinal  canal  and  there  the 
embryo  may  fasten  itself  by  its  suckers  to  the  walls 
and  draw  therefrom  its  nourishment  as  it  gradually 
grows  into  the  fully  developed  tapeworm. 

Tenia  Solium. — Tenia  solium,  or  pork  tape- 
worm, has  a  very  small  head  with  four  suckers  and 
a  rostellum  surrounded  by  a  double  row  of  hooks, 
20  to  30  in  number.  With  these  hooks  as  well  as  with  its  suckers  the 
pork  tapeworm  attaches  itself  to  the  mucous  membrane  much  more  firmly 
than  does  the  beef  tapeworm.  Behind  the  head  is  a  very  thin  neck  passing 
into  a  tape-shaped  body  that  is  divided  into  segments,  which  when  mature 


Fig.  32.— Tenia  Sagi- 
nata.     (Strumbell.) 


212 


INTESTINAL    PARASITES 


are  10  mm.  long  and  6  mm.  hroad.  Tlio  fully  developed  worm  may  be  20 
feet  in  length.  The  uterus,  which  fills  the  matured  segments,  differs  from 
that  of  the  beef  tai)ewnrm  in  that  its  central  canal  is  heavier  than  its 
branches  heavier  and  more  irregular  in  form.    The  eggs  are  globular  with  a 


Fig.  33. — Scolex,  Egg  and  Ripe  Segments  of  Tenia  Solium.     (Wood.) 

diameter  .03  mm.  The  life  cycle  of  this  tapeworm  is  similar  to  that  of  the 
beef  tapeworm  except  that  its  embryo  stage  is  passed  in  the  hog.  Infection 
therefore  occurs  from  eating  raw  pork. 

Hymenolepis  Nana. — Hymenolepis  nana,  or  the  dwarf  tapeworm,  is, 
according  to  Schloss,  a  common  intestinal  parasite  in  children.  He  found 
it  in  14  out  of  230  dispensary  patients.  Its  average  length  is  14  to  16  mm. ; 
its  distal  half  is  broad,  its  proximal  half  narrow.  The  segments  are  3  to  6 
times  as  broad  as  they  are  long;  the  head  is  globular,  carries  four  suckers 
and  a  rostellum  with  twenty  or  thirty  bifid  booklets.  Its  eggs  are  slightly 
oval  and  have  two  widely  spaced  membranes.  From  the  inner  membrane 
filaments  spring  which  ramify  in  the  space  between  the  membranes.  The 
habitat  of  this  tapeworm  is  the  upper  two-thirds  of  the  ileum.  Six  of  the 
fourteen  cases  presented  no  symptoms ;  in  the  remaining  eight  the  symptoms 
were  similar  to  those  produced  by  other  tapeworms. 

BoTHRiocEPHALUS  Latds. — Bothrioccphalus  latus,  or  fish  tapeworm, 
has  an  oval-shaped  head  with  two  elongated  depressions  serving  the  pur- 
pose of  suckers,  which  attach  it  to  the  intestinal  canal.  It  is  the  largest  of 
all  the  tapeworms,  reaching  a  length  of  30  or  40  feet.  The  segments  or 
links  are  only  5  mm.  long  and  about  14  mm.  wide,  making  a  characteristic 
differentiation  between  this  and  other  tapeworms.     The  slight  length  and 


IXTESTINAL    CESTODES  213 

great  breadth  of  these  segments  present  to  the  naked  eye  a  characteristic 
picture.  The  uterus  is  simpler  in  form,  having  only  5  or  6  branches.  The 
eggs  are  oval,  yellovrish-brown  in  color,  are  .07  mm.  long  and  .045  mm. 
broad,  and  they  have  at  their  top  a  peculiar  cap  or  lid  which  has  the  appear- 
ance of  closing  the  egg  cavity.  The  life  cycle  of  this  worm  is  the  same  as 
other  tapeworms  except  that  its  larval  or  embryo  stage  is  passed  in  the 
body  of  certain  fishes ;  the  pike,  the  perch,  the  trout,  and  the  salmon  are  its 
most  common  hosts.  Infection  occurs  from  eating  raw  fish  thus  infected. 
This  worm  is  most  common,  therefore,  among  the  fish-eating  population 
along  the  lakes  and  seashore. 

Tenia  Elliptica. — Tenia  elliptica,  or  the  dog  or  cat  tapeworm,  has 
upon  its  head  four  suckers  and  a  rostellum  with  fifty  or  sixty  hooks  which 
enable  it  to  attach  itself  most  firmly  to  the  mucous  membrane  of  the  in- 
testinal canal.  Its  links  are  8  mm.  long  and  2  mm.  broad.  These  long  and 
narrow  links  differentiate  it  from  other  tapeworms.  It  passes  its  larval 
stage  in  the  lice  of  the  house-dog  or  cat,  and  these  insects  are  swallowed  by 
these  animals  and  can  be  conveyed  to  children  who  play  with  them.  This 
worm  is  not  of  common  occurrence,  but  the  great  majority  of  the  cases  oc- 
cur in  children. 

Symptomatology. — The  habitat  of  the  full-grown  tapeworm  is  in  the 
intestine,  and  the  vague  symptom  group  which  it  causes  comes  largely 
from  the  irritation  which  it  there  produces.  Indigestion,  nausea,  head- 
.ache,  nervous  irritability,  sleeplessness,  and  in  rare  instances  more  severe 
nervous  symptoms  may  result.  This  symptom  group,  however,  has  nothing 
whatever  characteristic  in  it,  since  in  the  majority  of  instances  it  is  almost 
or  quite  absent,  the  child  appearing  in  normal  health.  In  a  very  small  per 
cent,  of  the  cases  of  Bothriocephalus  latus  there  occurs  a  very  severe  form 
of  anemia.  Eosinophilia  and  a  mild  simple  anemia  occur  in  nearly  all  chil- 
dren who  have  had  tapeworm  for  any  length  of  time. 

Diagnosis. — Diagnosis  in  nearly  every  instance  is  made  by  seeing  the 
segments  of  the  worms  in  the  stools.  The  parents  or  nurses  can  scarcely 
overlook  for  any  length  of  time  the  tapeworm  segments;  as  they  mature 
they  are  broken  off  and  escape  by  the  rectum.  The  cases,  therefore,  come 
to  the  physician  with  a  diagnosis  made.  If,  however,  there  be  any  doubt 
an  active  cathartic  may  be  given  to  carry  away  segments  of  the  worm.  Fail- 
ing in  this  the  fecal  matter  may  be  examined  microscopically  for  the  eggs. 

Differential  Diagnosis. — The  differential  diagnosis  of  the  varieties  of 
tapeworm  can,  as  a  rule,  be  made  by  carefully  studying  the  ripe  segments, 
and  may  be  of  considerable  importance,  especially  between  the  tenia  solium 
and  the  tenia  saginata,  the  two  most  common  varieties.  If  the  tenia  solium 
be  present  the  treatment  is  more  urgent  and  should  be  more  energetic,  since 
it  fastens  itself  more  tightly  to  the  intestinal  canal  by  booklets,  and  there  is 
also  greater  danger  in  this  form  from  cysticerci  or  the  encysted  embryos, 
which  may  result  from  the  eggs  of  tenia  solium,  finding  tlieir  way  into  the 
stomach.  In  such  instances  the  child  becomes  the  intermediary  host,  and 
the  embryo,  formed  in  its  intestinal  canal  from  the  egg,  passes  through  the 


2U  INTESTINAL   PARASITES 

intestinal  wall  and  finds  a  lodgment  in  the  nmscles,  brain,  or  other  organs, 
where  it  may  jirodnce  disease  even  after  the  intestinal  canal  of  the  child 
has  l)een  entirely  cleared  of  tapeworms. 

Treatment. — The  remedies  used  for  the  treatment  of  tapeworm  are 
more  or  less  toxic  and  more  or  less  irritating  to  the  gastrointestinal  canal. 
They  should  therefore  be  used  with  caution,  and  in  every  case  the  question 
must  be  decided  whether  the  child  is  in  a  proper  physical  condition  to 
undergo  the  treatment.  In  all  cases  where  the  child  is  acutely  ill  from 
other  diseases,  especially  from  gastrointestinal  troubles,  and  in  all  cases 
where  it  is  weak  and  malnourished  from  some  other  chronic  disease,  it  is 
better  to  postpone  the  treatment  until  it  can  at  least  be  put  in  a  fair  con- 
dition of  health.  During  this  time  the  child  should,  at  intervals  of  four  or 
five  davs,  be  given  doses  of  castor  oil  for  the  purpose  of  breaking  off  sections 
of  the  worm  and  discharging  them.  In  this  way  the  intestinal  irritation 
may  be  modified  and  the  danger  of  cysticercus  minimized. 

The  Cure. — After  a  day  of  preparatory  treatment,  during  which  the 
child  has  little  to  eat  and  is  given  at  bedtime  a  saline  laxative,  the  medi- 
cines for  stupefying  and  expelling  the  worm  are  given  early  the  next  morn- 
ing on  an  empty  stomach.  In  this  country  the  oleoresin  of  aspidium  (filix 
mas)  has  been  very  generally  and  very  successfully  used.  It  is  perhaps  the 
most  satisfactory  of  all  remedies.  It  should  be  given  in  doses  of  from  7  to 
30  minims,  depending  upon  the  age  of  the  child.  In  infancy  it  is  advisable 
to  begin  with  from  5-  to  7-minim  doses;  if  this  treatment  fails,  at  its  next 
administration  the  dose  may  be  increased;  for  a  child  three  years  of  age  10 
to  15  minims  may  be  given ;  for  a  child  six  years  of  age  30  minims.  Two 
doses  of  the  size  above  noted  should  be  administered,  one  when  the  child 
awakens  in  the  morning  and  one  an  hour  later.  The  child  should  then  be 
kept  as  quiet  as  possible  without  food.  Four  or  five  hours  after  the  last 
dose  of  male  fern  a  saline  laxative  should  be  administered.  This  is  to  be 
preferred  to  castor  oil,  as  it  is  less  likely  to  provoke  vomiting  and  as  there 
is  a  suspicion  that  oil  increases  the  toxic  action  of  filix  mas.  One  or  two 
hours  after  the  laxative  small  quantities  of  food  in  the  form  of  beef  broth 
may  be  commenced.  This  treatment  commonly  results  in  the  expulsion  of 
the  entire  worm.  A  careful  examination  should  be  made  by  the  nurse  of 
the  fecal  matter  expelled  and  every  particle  of  the  worm  carefully  saved  for 
the  physician's  examination.  The  object  of  this  examination  is  to  find  the 
head  of  the  tapeworm ;  if  this  be  found  a  cure  may  be  assumed,  since,  as  a 
rule,  only  one  worm  is  present  at  a  time.  If  the  head  is  not  found  one  is 
always  in  doubt,  and  two  weeks  later  the  same  treatment  may  be  repeated. 
If  the  head  is  not  then  found  it  is  advisable  to  wait  until  time  determines 
whether  the  child  has  been  cured  or  not.  If  after  a  number  of  weeks  the 
segments  again  appear  in  the  stool,  the  same  treatment  is  repeated,  giving 
one-third  larger  dose  of  the  male  fern.  It  is  not  commonly  necessary  to 
repeat  this  cure  again,  since  this  treatment  in  the  great  majority  of  in- 
stances is  successful.  Following  the  giving  of  the  male  fern  and  the 
cathartic,  the  child  should  for  a  few  days  be  carefully  digted  to  avoid  gastro- 


ASCAEIS    LUMBKICOIDES  315 

intestinal  irritation.  The  best  form  for  administering  oleoresin  of  aspidium 
will  depend  upon  the  age  of  the  child.  If  the  child  is  old  enough  it  may  be 
given  in  capsules,  if  not,  in  an  emulsion  of  equal  parts  of  gum  tragacanth 
and  simple  elixir.  A  favorable  vehicle  is  thus  offered  for  the  administration 
of  a  drug  which  not  only  is  very  distasteful  to  the  child,  but  may  produce 
nausea  and  vomiting  and  thus  necessarily  postpone  the  cure. 

Prophylactic  Treatment. — As  rare  beef,  and  beef  juice  made  from 
raw  beef,  are  such  common  articles  of  diet  with  young  children,  it  is  wise 
to  explain  to  parents  that  there  is  a  slight  danger  of  contracting  tapeworm 
from  eating  these  foods.  This  danger  can  be  removed  by  stopping  these 
foods  and  permitting  children  to  have  only  beef,  pork  and  fish  that  have 
been  well  cooked,  or  it  may  be  minimized  by  carefully  scrutinizing  all  meat 
for  cysticerci,  before  preparing  raw  foods  for  children.  This  latter  method 
of  prophylaxis  with  reference  to  rare  beef  and  beef  juice  is  to  be  advised 
because  there  is  only  the  slightest  possible  danger,  with  tliis  precaution,  that 
the  child  may  contract  tapeworm,  and  the  disease  itself  is  not  of  sufficient 
seriousness  to  warrant  the  elimination  from  the  child's  diet  of.  two  of  the 
most  important  foods  during  this  period  of  growth  and  development. 
Nevertheless,  as  a  fundamental  principle  of  prophylaxis  one  should  advise, 
with  these  exceptions,  that  all  meat  foods  should  be  well  cooked. 

To  prevent  the  spread  of  this  disease  by  those  infected,  it  is  necessary 
that  their  fecal  discharges  be  carefully  disposed  of.  In  the  city  this  may 
be  done  by  giving  great  care  to  the  personal  cleanliness  of  the  child,  burn- 
ing the  segments  as  they  appear  in  the  stools,  scalding  out  all  vessels  used 
for  the  reception  of  fecal  matter,  and  flushing  the  feces  into  the  sewer 
as  soon  as  possible.  In  the  country,  where  sanitary  plumbing  is  not  used, 
it  is  best  to  burn  all  fecal  discharges. 

ASCARIS  LUMBRICOIDES 

Characteristics. — This  is  the  common  round-worm,  has  a  pale  red  color, 
is  cylindrical  in  shape  and  has  pointed  extremities,  resembling  the  ordinary 
fishing  worm.  The  male  is  about  20  cm.  long  and  4  mm.  thick  and  its  tail 
is  curled  up  over  its  abdomen.  The  female  is  larger,  being  about  30  cm. 
long  and  5  mm,  thick.  The  female  produces  millions  of  eggs  which  are 
disseminated  in  great  profusion  through  the  fecal  contents  of  the  intestinal 
canal.  The  eggs  measure  from  .05  to  .06  mm.  in  length  and  are  both 
round  and  oval  in  shape.  The  embryos  develop  only  from  the  round  eggs; 
the  oval  form  is  unfruitful.  The  outer  layer  of  these  eggs  has  a  rough 
nodular  surface  and  is  yellowish-brown  in  color.  The  life  cycle  of  the 
round-worm  does  not  require  an  intermediate  host.  The  eggs  propagate 
rapidly  in  moist  earth,  so  that  the  surroundings  of  the  patient  may  be 
readily  contaminated  from  the  intestinal  discharges.  This  leads  to  the 
spread  of  this  disease  among  the  uncleanly,  among  whom  this  condition  is 
most  frequently  found.  More  than  one  worm  is  commonly  present  and 
they  may  exist  in  great  numbers,  so  great,  in  fact,  that  they  may  entwine 


216 


INTESTINAL   PARASITES 


themselves  in  masses  of  sufficient  size  to  produce  intestinal  obstruction. 

They  may  migrate  to  all  portions  of  the  gastrointestinal  canal,  appearing 
in  the  stomach  and  producing  gastric  irritation  and 
vomiting ;  occasionally  finding  their  way  into  the  larynx, 
trachea  and  bronchi,  producing  there  serious  symp- 
toms of  obstruction.  They  may  enter  the  bile  duct, 
causing  jaundice  and  even  abscess  of  the  liver,  and  by 
penetrating  into  the  appendix  may  produce  appendi- 
citis. 

Symptomatology. — In  the  great  majority  of  in- 
stances constitutional  symptoms  are  absent.  But  there 
may  be  more  or  less  intestinal  irritation,  which  in 
young  and  delicate  children  is  marked  by  digestive 
disturbances  and  mild  nervous  symptoms,  largely  reflex 
in  their  nature.  The  appetite  may  be  lost  or  perverted, 
slight  nausea  and  diarrhea  may  occur,  and  the  child 
may  be  restless,  irritable,  sleepless  and  complain  of 
headache.  Picking  at  the  nose  and  rectal  irritation  are 
common,  but  not  at  all  characteristic,  symptoms.  In 
rare  instances  more  severe  nerv- 
ous symptoms,  such  as  convul- 
sions, may  occur.  The  writer  ob- 
served one  such  instance  in  an 
apparently  normal  child,  eight 
years  of  age,  who  lay  in  convul- 

FiG.34.— AscARisLuM-  giojis  for  eight  or  ten  hours,  and 
BRicoiDEs,    Female,  .  t-    ,   i  i-        -,         i      ■ 

Head  and  Male,      was  immediately  relieved  and  at 

once  convalescent  on  the  passage 
of  a  large  ball  of  tightly  matted  round-worms.  The  convulsions  in  such 
cases  may  in  part  be  the  result  of  the  intestinal  obstruction  and  resulting 
intoxication  which  the  ball  of  worms  produces,  or  they  may  be  caused,  as 
the  French  writers  believe,  from  the  poisons  which  the  round-worm  ex- 
cretes into  the  intestinal  canal.  Eosinophilia  may  be  associated  with  the 
presence  of  these  worms. 

Diagnosis. — The  above  symptom  group  varies  so  greatly  in  different  cases 
and  marked  symptoms  are  so  commonly  absent,  that  the  diagnosis  of 
round-worms  is  ordinarily  made  by  seeing  the  worms  in  the  intestinal  dis- 
charges. When  this  disease  exists,  a  cathartic,  such  as  castor  oil,  will  al- 
most certainly  reveal  the  presence  of  the  worms  in  the  stools,  but  a  much 
more  accurate  method  of  diagnosis  is  to  examine  the  feces  under  the  micro- 
scope. The  eggs  will  always  be  found  in  abundance.  This  latter  method 
of  examination  is  so  reliable  that  it  is  advisable,  following  the  treatment 
for  this  condition,  to  make  a  second  microscopical  examination  of  the 
feces  to  determine  whether  the  eggs  have  entirely  disappeared. 

Treatment. — Santonin  is  a  specific  for  this  condition.  It  is  advisable 
to  either  combine  it  or  follow  it  with  calomel,  and  some  hours  later  by  a 


Fig.  35. — Egg  of  As- 
cari8  lumbricoides. 
(Wood.) 


OXYURIS  VEEMICULAEIS  217 

saline  laxative  or  by  castor  oil.  Two  doses  of  the  santonin  and  calomel 
should  be  given,  the  first  dose  on  an  empty  stomach  before  breakfast,  and 
the  second  at  bed-time,  to  be  followed  the  next  morning  by  the  castor  oil. 
The  dose  of  santonin  is  one-half  grain  for  a  child  one  year  of  age  and 
one  grain  for  a  five-year-old  child.  Larger  doses  may  produce  poisoning. 
This  treatment  may  be  repeated  after  an  interval  of  one  week,  and  in  the 
great  majority  of  instances  a  cure  is  effected.  The  following  prescription 
offers  a  suitable  form  for  the  administration  of  this  drug : 

]R     Santonin    a^s.  i 

Calomel   gpg   j 

Sacchari  albi grs.  vi 

M.     Div.  in  chart  No.  2. 

Sig.  One  before  breakfast  and  one  after  supper  for  a  child  one  year  of  age. 

All  of  the  ingredients  of  this  prescription  may  be  doubled  for  a  child 
five  years  of  age. 

Trichuris  Trichiura. — Trichuris  trichiura,  or  the  whip-worm,  is  a 
common  intestinal  parasite.  It  is  a  whip-shaped  round  worm,  about  two 
inches  in  length,  which  has  its  habitat  in  the  large  intestine.  It  is  of 
little  clinical  or  pathological  importance,  since  it  rarely  produces  either 
constitutional  or  local  symptoms. 


OXYURIS  VERMICULARIS 

Characteristics. — Oxyuris  vermicularis  is  the  ordinary  thread-worm.  It 
is  not,  like  the  round-worm,  so  largely  confined  to  the  uncleanly,  but  may 
occur  among  all  classes  of  society.  It  is  very  small  and  looks  not  unlike 
a  piece  of  white  thread;  is  spindle-shaped  and  white  in  color.  The  male 
is  between  3  and  4  mm.  long,  and  the  tail  is  curved  toward  the  abdominal 
surface.  The  female  is  much  larger,  9  or  10  mm.  in  length  and  two  or 
three  times  as  thick  as  the  male,  but  its  tail  is  not  curved  forward.  The 
female  produces  thousands  of  eggs,  oval  in  shape  and  about  .05  mm.  long. 
The  eggs,  however,  of  this  species  are  not  so  important  from  a  diagnostic 
standpoint  as  they  are  in  the  round-worm.  The  thread- worm  requires 
no  intermediate  host.  The  child  may  reinfect  itself  or  spread  the  disease 
among  other  children  after  contaminating  its  fingers  by  scratching  the 
anus.  The  female  lives  in  the  large  intestine,  and  the  embryos  make  their 
way  into  the  small  intestine  where  the  males  predominate,  but  as  they 
mature  both  males  and  females  migrate  to  the  large  intestine.  As  the  eggs 
and  worms  are  discharged  with  the  feces  the  surroundings  of  the  child 
are  contaminated.  This  offers  a  favorable  opportunity  not  only  for  the 
reinfection  of  the  child,  but  for  the  spread  of  the  disease  to  other  children. 
Symptomatology. — The  irritation  which  these  worms  produce  in  the 
colon  may  result  in  mucous  discharges.  Pruritus  ani  is  the  most  common 
and  the  most  troublesome  symptom.  The  intense  itching  of  the  rectum, 
which  is  much  worse  at  night,  is  due  to  the  fact  that  the  worms  migrate  at 


218 


INTESTINAL   PARASITES 


this  time  to  the  outer  rectal  folds  and  they  may  there  be  seen  by  pressing 
aj)art  the  folds  of  the  anus.     This  itching  of  the  rectum  causes  the  child 
to  be  sleepless  and  irritable,  and  results  in  scratching  and  tearing 
the  part  with  the  fingers;  this  is  usually  done  during  sleep.     The 
traumas  resulting  from  scratching  very  commonly  produce  eczema 
and  scars  about  the  anus.     Thread-worms  may  be  the  reflex  excit- 
ing cause  of  nocturnal  incontinence  of  urine,  pseudo-masturbation, 
and  night  terrors.     Loss  of   weight,  anemia  and  headache  may 
occur.     The    most    serious    localized    disturbance 
which  can  be  produced  by  these  worms  in  the  large 
intestine  is  appendicitis,  but  this  is  a  rare  occur- 
rence. 

Diagnosis. — The  symptom  group  above  outlined 
at  least  suggests  the  presence  of  the  tli read-worm, 
and  the  diagnosis  is  confirmed  by  making  an  ex- 
amination of  the  anus.  For  reasons  above  given 
this  is  more  successful  if  the  inspection  is  made 
some  hours  after  the  child  has  gone  to  bed.  If  the 
worms  are  not  found  in  the  rectal  folds  an  enema 
should  be  given,  and  in  the  resulting  discharge  the 
worms  can  be  seen.  A  dose  of  castor  oil  will  also 
answer  the  purpose  of  bringing  these  parasites  to 
light. 

Treatment. —The  most  effective  remedy  is  flush- 
ing the  colon  with  normal  salt  solution.  High  in- 
jections that  completely  irrigate  and  wash  the  mu- 
cus out  of  this  organ  are  necessary  to  successful 
treatment.  These  irrigations  should  be  followed  by 
6  to  10  ounces  of  infusion  of  quassia,  injected 
high  into  the  colon;  this  should  be  repeated  every 
day  for  four  or  five  days,  and  after  a  period  of  four 
or  five  days'  rest  the  irrigation  may  again  be  resorted  to.  It  may  be  neces- 
sary in  obstinate  cases  to  repeat  this  treatment  as  many  as  four  or  five 
times,  but  the  great  majority  of  cases  are  cured  after  the  second  or  third 
course  of  injections.  Each  time  before  beginning  the  irrigation  it  is  ad- 
visable to  give  a  preliminary  dose  of  calomel  and  santonin,  of  each  one- 
half  grain,  followed  by  castor  oil  or  some  other  cathartic.  This  treatment 
serves  the  purpose  of  driving  these  parasites  out  of  the  small  intestine 
where  they  can  be  reached  by  the  colon  irrigation. 

In  rare  instances  one  comes  in  contact  with  a  case  of  thread-worms 
that  fails  to  respond  to  treatment.  Some  of  these  cases  may  be  due  to  a 
lack  of  prophylactic  treatment  in  connection  with  the  cure  above  given. 
The  ova  are  so  commonly  found  under  the  finger  nails  as  a  result  of  scratcli- 
ing,  that  in  every  case  the  greatest  cleanliness  should  be  observed.  The 
child's  hands  and  finger  nails  should  be  kept  clean  with  soap  and  water, 
and  in  obstinate  cases  the  child  should  sleep  with  closed  pajamas  so  as 


Fig.  36. — Oxtioris  Vermi- 

CULARI8,  FeMALK,  IMMA- 
TURE Female  and  Male. 


ETIOLOGY  3iy 

to  keep  the  fingers  from  coming  in  contact  with  the  rectum  during  sleep. 
Fecal  discharges  should  be  disposed  of  with  the  same  care  and  in  the  same 
manner  as  just  described  under  the  treatment  for  Ascaris  Lumbricoides. 


CHAPTEK  XXV 

INTESTINAL    INTUSSUSCEPTION 

Intestinal  intussusception  is  the  invagination  of  one  part  of  the  intes- 
tine by  another;  the  upper  portion  of  the  gut  commonly  slips  into  the 
lower,  but  the  reverse  of  this  may  take  place,  the  lower  portion  slipping 
into  the  upper.  This  produces  a  cylindrical  tumor  composed  of  three 
parallel  layers  of  intestine.  This  tumor  may  itself  again  be  invaginated  or 
swallowed  up  by  the  neighboring  intestine;  this  double  invagination  is 
much  more  likely  to  occur  where  the  small  intestine  alone  is  involved  in 
the  process.  In  intestinal  invagination  the  mesentery  is  also  swallowed 
up  and  drags  at  the  head  of  the  invaginated  gut ;  this  greatly  increases  the 
traumatism  and  causes  inflammatory  processes  in  the  affected  part;  it  also 
aids  materially  in  producing  the  more  or  less  complete  obstruction  of  the 
bowels,  since  the  dragging  of  the  invaginated  mesentery  pulls  the  invagi- 
nated gut  out  of  line  with  the  intestinal  canal. 

Intussusception  may  occur  throughout  the  intestinal  canal,  but  in  the 
vast  majority  of  instances  it  involves  some  portion  of  the  ileum  or  colon 
or  both,  and  the  different  varieties  depend  upon  the  portion  of  the  intes- 
tine involved.  The  ileocecal  type  is  the  most  common;  it  includes  70  or 
80  per  cent,  of  all  cases;  in  this  form  the  colon  swallows  up  the  cecum 
and  ileum ;  the  ileocecal  valve  preceding  the  mass  may  reach  the  rectum. 
The  ileocolic  type  embraces  from  10  to  15  per  cent,  of  the  cases;  in  this 
form  the  ileum  slips  through  the  ileocecal  valve,  the  valve  remaining  in 
position.  The  colic  type  embraces  2  or  3  per  cent,  of  the  cases;  in  this 
condition  the  colon  slips  into  itself,  and  passes  downward  toward  the 
rectum.  The  ileac  type  embraces  from  5  to  8  per  cent.;  in  this  condition 
the  small  intestine  is  telescoped  into  itself  and  this  commonly  occurs  in  the 
ileum. 

Etiology. — Age  is  an  important  predisposing  factor,  as  intussusception 
occurs  in  children  very  much  more  commonly  than  it  does  in  adults.  It 
is  observed  most  frequently  in  the  second  half  of  the  first  year  and  dimin- 
ishes thereafter,  but  is  not  uncommon  up  to  the  sixth  or  seventh  year. 
It  is  by  far  the  most  common  form  of  intestinal  obstruction  observed  in 
childhood.  It  occurs  more  frequently  in  weak,  malnourished  children,  and 
especially  in  those  that  have  suffered  from  previous  intestinal  disease;  in 
these  children  the  musculature  of  the  intestine  is  weak,  irritable  and  sub- 
ject to  abnormal,  irregular,  peristaltic  contractions,  which  are  the  great 
exciting  causes  of  this  disease.  These  abnormalities  in  peristalsis  may  be 
excited  by  constipation,  intestinal  disorders,  improper  food,  injury  to  the 


220  INTESTINAL  INTUSSUSCEPTION 

abdomen  and  irritations  and  inflammations  of  Meckel's  diverticulum  and 
the  appendix. 

Pathology.  — As  previously  noted,  the  swallowing  of  both  mesentery  and 
intestine  increases  the  engorgement,  aggravates  the  strangulation  and  pro- 
duces complete  intestinal  obstruction  which  results  in  necrosis  and  gangrene 
of  the  invaginated  gut.  Snow,  of  Buffalo,  reported  a  case  in  an  infant 
seven  months  of  age,  who  for  sixteen  days  had  had  symptoms  of  intussuscep- 
tion ;  six  inches  of  gangrenous  intestine  which  protruded  from  the  rectum 
was  removed  and  the  infant  recovered.  In  the  chronic  cases  the  obstruc- 
tion is  not  complete,  but  the  invaginated  intestine  is  held  firmly  in  posi- 
tion by  inflammatory  tissues. 

Symptomatology.  — General  Symptoms. — This  disease  begins  suddenly, 
not  uncommonly  during  sleep,  with  severe  intestinal  pain  which  recurs  in 
paroxysms.  The  pain  is  associated  with  vomiting,  usually  severe  and  per- 
sistent in  character,  and,  after  a  few  hours,  with  the  passage  from  the 
bowels  of  bloody  mucus  and  very  little  or  no  fecal  matter.  This  symptom 
group  is  practically  characteristic  of  the  disease,  and  of  great  importance 
is  the  fact  that  these  symptoms  are  associated  in  the  beginning  with  little 
or  no  fever. 

The  pain  is  similar  to  that  which  occurs  in  severe  intestinal  colic,  the 
infant  cries  loudly,  draws  its  legs  upon  its  abdomen  and  squirms  with  pain ; 
after  a  time  the  paroxysm  disappears,  only  to  return  with  the  same  severity 
after  a  longer  or  shorter  interval.  The  attacks  of  pain  are  supposed  to  be 
associated  with  violent  peristalsis  and  perhaps  to  mark  the  various  steps 
in  the  progress  of  the  invagination.  After  a  few  hours  they  become  less 
severe  and  from  this  time  on  the  intestinal  colic  is  no  longer  a  prominent 
symptom  of  the  disease. 

Vomiting  occurs  early  and  very  frequently  continues  throughout  the 
course  of  the  disease.  The  intervals  between  the  paroxysms  may  be  meas- 
ured by  minutes  or  by  hours.  The  vomited  matter  consists  first  of  food, 
then  of  mucus,  perhaps  stained  with  blood,  then  bile,  and  in  some  instances 
fecal  matter;  this  is  more  marked  in  older  children  and  is  associated 
with  complete  intestinal  obstruction.  In  a  small  percentage  of  the  cases 
vomiting  is  not  so  prominent  a  symptom;  it  may  come  on  late  and  recur 
only  once  or  twice  in  twenty-four  hours. 

Intestinal  Discharges. — The  bloody  mucus  which  is  discharged  in  80 
per  cent,  of  the  cases,  and  commonly  within  the  first  twenty-four  hours,  is 
our  most  valuable  symptom  in  the  diagnosis  of  this  disease.  Gibson  re- 
gards it  when  taken  in  connection  with  the  other  symptoms  as  pathogno- 
monic. The  blood  in  rare  instances  is  discharged  in  large  quantities;  it 
usually,  however,  occurs  in  such  small  quantities  as  only  to  slightly  tinge 
the  mucous  discharges.  These  discharges  of  bloody  nmcus  may  be  associated 
with  tenesmus  and  relaxation  of  the  rectal  sphincter  when  the  intussuscep- 
tion approaches  the  rectum.  With  the  onset  of  this  condition  the  first 
intestinal  discharge  may  be  normal,  followed  by  slightly  loose  movements, 
which  within  the  first  twenty-four  hours  consist  almost  entirely  of  bloody 


DIAGNOSIS  221 

mucus,  with  little  or  no  fecal  matter.  With  the  increase  in  the  obstruc- 
tion, which  commonly  becomes  complete,  the  discharge  of  gas  and  fecal 
matter  ceases.  In  some  instances,  however,  small  quantities  of  fecal  mat- 
ter and  gas  may  escape  through  the  invaginated  intestine  for  several  days. 
In  the  rare  cases  of  chronic  intestinal  obstruction  occurring  in  older  chil- 
dren, gas  and  fecal  matter  continue  to  be  discharged  throughout  the  dis- 
ease. When  gangrene  occurs  the  discharges  may  contain  shreds  of  putrid, 
foul-smelling  tissue. 

Fever. — In  the  beginning  intestinal  intussusception  is  an  afebrile  con- 
dition. After  the  second  or  third  day  there  may  be  a  slight  rise  in  temper- 
ature and  if  the  child  lives  for  four  or  five  days  the  temperature  rises  as 
a  result  either  of  intestinal  infection  or  of  peritonitis. 

Physical  Examination. — A  tumor,  which  can  be  found  in  from  40 
to  50  per  cent,  of  these  cases,  should  be  carefully  searched  for;  abdominal 
palpation,  however,  should  be  made  when  the  child  is  free  from  pain  and 
the  abdomen  completely  relaxed;  anesthesia  may  be  necessary  in  some 
cases;  the  tumor,  which  is  an  elongated  tender  mass,  is  commonly  found  in 
the  transverse  or  descending  colon.  The  presence  of  localized  tenderness 
may  assist  in  the  localization  of  the  tumor.  The  examination  per  rectum 
W'ith  the  finger,  in  30  to  40  per  cent,  of  the  cases,  will  reveal  the  invaginated 
intestine  which  has  pushed  down  almost  or  quite  into  the  rectum  and  the 
examining  finger  on  withdrawal  may  be  covered  with  bloody  mucus.  This 
examination  should  be  made  in  every  instance,  since  the  tumor  after  all 
is  the  only  pathognomonic  sign  of  this  disease.  The  general  appearance  of 
the  child  is  of  value  in  the  diagnosis ;  in  severe  cases  there  is  marked  pros- 
tration, and  the  infant  has  a  pale,  anxious  expression,  which  during  an 
attack  of  pain  may  be  associated  with  cyanosis  and  with  a  rapid  feeble 
pulse. 

Course. — The  course  of  this  disease  may  be  very  acute,  the  child 
dying  within  the  first  twenty-four  hours;  these  rapidly  fatal  cases,  how- 
ever, are  very  rare."  In  most  instances  it  lasts  from  a  week  to  ten  days; 
it  reaches  the  crisis  more  rapidly  in  infants  than  it  does  in  older  children. 
When  the  case  becomes  chronic  it  may  be  prolonged  indefinitely. 

Prognosis. — This  depends  largely  upon  an  early  diagnosis  and  early 
surgical  interference;  it  is  much  more  favorable  in  infants  than  in  older 
children ;  if  the  diagnosis  is  made  in  the  first  twenty-four  hours  more  than 
60  per  cent,  recover.  The  average  mortality  according  to  Gibson  is  53 
per  cent. 

Diagnosis. — This  is  made  by  the  sudden  onset  of  a  severe  intestinal 
colic,  associated  with  vomiting  and  with  the  passage  of  bloody  mucus,  but 
with  the  discharge  of  little  or  no  fecal  matter.  This  symptom  group  oc- 
curring as  an  afebrile  condition  is  sufficient  to  warrant  an  exploratory 
laparotomy,  even  if  the  physical  examination  fails  to  reveal  a  tumor.  The 
demonstration  of  the  tumor,  however,  either  by  abdominal  palpation  or 
rectal  examination,  makes  the  diagnosis  certain.  This  disease  should  not 
be  confounded  with  enterocolitis,  which  is  from  the  onset  a  distinctly 


222  APPENDICITIS 

febrile  disease  presenting  an  entirely  different  symptom  group.  It  resembles 
tbis  disease  only  in  tbe  passage  i)er  rectum  of  bloody  mucus.  Acute  appen- 
dicitis may,  by  its  vomiting,  pain  and  obstinate  constipation,  suggest  in- 
tussusception. In  tliis  condition,  however,  the  bloody  stools  and  tumor 
are  absent,  and  the  disease  is  distinctly  febrile  from  its  onset.  The  further 
points  in  the  differential  diagnosis  of  this  condition  may  be  made  out  by 
a  study  of  the  symptoms  of  appendicitis. 

The  diagnosis  of  intussusception  from  other  forms  of  intestinal  ob- 
struction is,  as  a  rule,  not  difficult,  and  in  this  differentiation  practically 
only  two  conditions  have  to  be  considered,  viz.,  obstruction  from  fecal  impac- 
tion and  from  inflammatory  bands  caused  by  appendicitis  or  peritonitis. 
The  diagnosis  of  fecal  impaction  may  be  made  out  by  rectal  examination 
and  by  physical  examination  of  the  abdomen,  as  well  as  by  the  history  of  the 
case  and  the  results  of  the  preliminary  salt-water  enema.  Obstruction 
from  inflammatory  bands  may  be  determined  by  the  complete  occlusion 
(no  feces  or  gas),  the  severity  of  the  vomiting,  the  absence  of  bloody 
mucous  discharges,  and  the  presence  of  appendicitis  or  peritonitis. 

Treatment.— No  time  should  be  lost  in  obtaining  surgical  relief,  as 
there  is  little  to  be  hoped  for  from  any  other  line  of  treatment,  and  much 
to  be  lost  by  postponing  surgical  treatment  in  the  hope  that  less  radical 
measures  will  relieve  the  condition.  All  writers  agree,  however,  that  no 
harm  can  come  from  the  introduction  into  the  colon  of  large  quantities 
(1  quart)  of  warm  normal  salt  solution.  In  giving  this  enema  the  child's 
hips  should  be  elevated  and  a  rectal  tube  inserted  into  the  sigmoid  flexure, 
and  through  this  tube,  from  the  bag  which  is  elevated  not  more  than  two 
feet  above  the  patient,  the  water  is  allowed  to  flow.  In  some  instances 
relief  has  followed.  The  forcible  introduction  of  water,  oil,  air  or  gas, 
for  the  purpose  of  reducing  the  intussusception,  is  accompanied  by  more 
or  less  danger;  rupture  of  the  intestine  has  occurred  during  these  manipu- 
lations. 

By  an  exploratory  laparotomy  the  surgeon  may  determine  the  char- 
acter of  the  operation  to  be  made.  It  may  be  found  that  a  simple  reduc- 
tion of  the  intussusception  is  all  that  is  necessary,  or  it  may  be  necessary 
to  shorten  the  mesentery  at  the  site  of  the  intussusception  to  prevent  its 
recurrence,  and  in  other  instances  a  resection  of  the  gut  may  be  obliga- 
tory. All  forms  of  intestinal  obstruction,  except  that  produced  by  fecal 
impaction,  are  essentially  surgical. 


CHAPTER  XXVI 

APPENDICITIS 

The  term  appendicitis,  as  now  used,  includes  periappendicitis,  typhlitis, 
perityphlitis  and  localized  abscess  and  peritonitis  occurring  in  the  appen- 
dicular region. 


PATHOLOGY  223 

Etiology.  — The  disease  is  rare  in  infancy,  but  after  the  second  year  of 
life  Ijecomes  much  moro  frequent  and  during  childhood  is  not  uncommon. 
Heredity,  as  Forchheimer  has  shown,  is  an  important  etiological  factor. 
The  hereditary  predisposition  may  depend  upon  inherited  anatomical  pe- 
culiarities of  the  appendix,  such  as  its  length,  location  and  patulency,  or 
upon  the  character  of  lymphoid  tissue  associated  with  it,  or  on  an  heredi- 
tary tendency  to  constipation;  at  any  rate  it  is  a  fact  that  this  condition 
may  be  a  "family"  disease  running  through  various  generations.  Among 
the  exciting  causes  are  constipation,  especially  fecal  impactions  in  the  ce- 
cum; colitis  involving  the  cecum  and  extending  to  the  appendix;  intes- 
tinal infections  which  destroy  the  normal  intestinal  flora  and  substitute 
therefor  pathogenic  flora,  such  as  the  bacillus  coli,  streptococci  and  staphy- 
lococci; foreign  materials  such  as  fecal  concretions;  seeds  and  undigested 
food;  intestinal  worms;  blows  upon  the  abdomen,  or  unusual  muscular 
exertion  lighting  up  a  latent  inflammatory  condition ;  and  lastly,  scarlatina, 
typhoid  fever,  tonsillitis  and  intestinal  grippe.  These  last-named  infections 
may  be  associated  with  cases  of  appendicitis.  Of  these  exciting  causes 
bacteria  are  undoubtedly  of  the  greatest  importance. 

Pathology. — The  appendix  in  the  child  is  commonly  located  lower  down 
in  the  ])elvis  than  it  is  in  the  adult.  This  position  of  the  appendix  and 
cecum  is  of  importance,  in  that  in  the  physical  examination  of  these  parts 
the  enlarged  appendix,  or  tumor  masses  resulting  from  appendicitis,  must 
Ije  felt  for  lower  down  and  often  under  the  anterior  spine  of  the  ilium. 
This  position  of  the  appendix,  often  in  the  little  pelvis,  may  direct  the 
burrowing  abscess  deep  down  into  the  floor  of  the  pelvis  and  up  on  the 
other  side  in  close  association  with  the  rectum.  The  location  of  the  ap- 
pendix, however,  in  the  child  is  even  more  variable  tlian  it  is  in  the 
adult;  it  not  infrequently  is  directed  upward  and  lies  back  of  the  cecum. 
The  variability  in  the  location  of  the  appendix  determines  the  various 
locations  of  the  abscess  and  inflammatory  thickenings  which  occur  in  this 
condition. 

The  forms  of  appendicitis  in  children  are  similar  to  those  occurring 
in  the  adult :  the  catarrhal,  the  ulcerative  and  the  gangrenous.  There  is, 
however,  on  the  part  of  the  child  an  apparent  predisposition  to  the  ulcer- 
ative or  perforative  variety,  since  these  cases  occur  in  relatively  larger  pro- 
portion. In  the  catarrhal  form  the  mucous  membrane  of  the  appendix  is 
congested,  inflamed,  and  its  lumen  distended  with  mucus  or  mucopus.  In 
these  cases  the  contents  of  the  appendix  are  discharged  into  the  cecum 
and  there  produce  more  or  less  irritation,  aggravating  an  old  colitis,  which 
may  have  been  the  original  cause  of  the  appendicitis.  At  any  rate  colon 
infection  and  attacks  of  subacute  colitis  occur  in  these  cases,  and  the  per- 
sistent factor  in  many  a  chronic  case  of  chronic  colitis  is  an-  existing  catar- 
rhal appendicitis.  In  the  ulcerating^or  perforating  form,  the  mucous  mem- 
brane of  the  appendix  becomes  infiltrated  and  finally  breaks  down  under 
the  infection  and  distention.  The  perforation  generally  occurs  near  the  end 
of  the  appendix,  which  not  uncommonly  holds  a  plug  of  hard  fecal  mat- 
16 


224  APPENDICITIS 

ter  or  a  quantity  of  mucus  and  pus,  which  by  their  pressure  have  facilitated 
the  rupture.  In  the  gangrenous  variety  a  portion  of  the  distal  end  of  the 
appendix  becomes  necrotic  and  sloughs  off ;  this  process,  which  is  perhaps 
due  to  some  disturbance  of  circulation,  allows  the  contents  of  the  appendix 
to  be  discharged  through  the  opening  produced  by  the  slough.  The  fecal 
and  other  concretions  present  in  both  the  ulcerative  and  gangrenous  types 
may  be  an  effect  rather  than  a  cause  of  the  appendicitis.  It  is  probable 
that  most  cases  of  appendicitis  would  remain  catarrhal  if  there  were  a  free 
opening  through  which  the  contents  of  the  appendix  could  be  discharged 
into  the  colon,  but  with  the  congestion  of  the  mucous  membrane  this  open- 
ing, at  all  times  insufficient,  becomes  more  tightly  closed,  shutting  up 
within  the  small  lumen  of  the  appendix  the  mucus  and  pus  formed  by 
the  inflammatory  process.  Various  microorganisms,  especially  the  colon 
bacillus,  streptococci  and  staphylococci,  play  an  important  role  in  the  etiol- 
ogy and  pathology  of  the  more  severe  cases. 

In  the  ulcerative  and  gangrenous  forms  of  appendicitis  the  appendix  is 
commonly  walled  off  by  an  inflammatory  exudation  which  catches  and 
holds,  at  least  temporarily,  the  infectious  material  discharged  from  the  ap- 
pendix. This  localized  abscess  thus  formed  may  burrow  into  the  pelvis 
as  previously  described,  may  make  its  way  up  behind  the  cecum  or  may 
even  present  itself  anteriorly,  perforating  the  skin;  it  more  commonly, 
however,  breaks  through  the  inflammatory  wall  which  surrounds  it  into 
the  general  peritoneal  cavity,  producing  septic  peritonitis.  General  peri- 
tonitis may  immediately  follow  rupture  of  the  appendix,  when  nature  has 
not  had  time  to  wall  off  an  inflammatory  pocket  for  the  reception  of  the 
infectious  material;  this  occurs  most  commonly  in  the  gangrenous  forms. 
Inflammatory  bands,  which  are  thrown  out  during  the  acute  process  and 
commonly  remain  for  some  time  after  recovery  from  the  attack,  may  catch 
and  strangle  loops  of  intestine,  thus  complicating  the  appendicitis  with 
an  acute  intestinal  obstruction.  This  is  a  danger  to  be  watched  for  during 
the  convalescence  of  operative  cases,  and  is  much  more  common  in  child- 
hood than  in  adult  life. 

Symptomatology. — This  disease  may  follow  an  indigestion,  or  be  coin- 
cident with  an  intestinal  infection.  The  initial  symptoms  are  severe  ab- 
dominal pain,  colicky  in  character,  recurring  at  intervals,  commonly  as- 
sociated with  vomiting,  which  may  or  may  not  be  repeated.  Constipation, 
obstinate  in  character,  is  the  rule ;  diarrhea  "may  occur ;  fever  is  present. 
This  symptom  group  occurs  with  such  clearness  as  to  at  least  suggest 
the  possibility  of  appendicitis,  which  should  lead  to  a  careful  physical 
examination,  upon  the  results  of  which  the  diagnosis  is  ordinarily  made. 

Physical  Examination. — The  child  commonly  assumes  the  recum- 
bent posture  and  lies  with  its  legs  flexed  upon  the  abdomen.  By  gentle 
palpation,  localized  tenderness  may  be  located  at  McBurney's  point,  but,  as 
a  rule,  it  is  lower  down,  on  or  below  the  level  of  the  superior  iliac  spine. 
The  amount  of  tenderness  on  pressure  is  to  be  estimated  largely  by  watch- 
ing the  child's  face  during  examination;  the   facial  expression  is   more 


SYMPTOMATOLOGY  226 

reliable  than  the  child's  answers  in  determining  the  question  of  localized 
tenderness.  This  examination  also  makes  out  the  presence  or  absence  of 
localized  resistance  of  the  muscles  in  the  right  iliac  region;  this  localized 
muscular  tension  is  of  the  very  greatest  value  in  the  diagnosis,  when 
present  in  association  with  the  symptom  group  above  given  it  indicates 
a  rather  active  appendicitis;  this  is  especially  true  in  young  children,  A 
tumor  or  thickening  of  the  tissues  around  the  appendix,  or  the  enlarged 
appendix  itself,  may  be  made  out  by  careful  bimanual  examination.  In 
making  this  manipulation  the  fingers  of  the  left  hand  are  pressed  deeply 
into  the  back  opposite  McBurney's  point,  and  the  right  hand  in  opposition 
to  it  is  pressed  gently  down  into  the  region  of  the  appendix,  carefully  pal- 
pating the  entire  region,  especially  low  down  in  the  pelvis.  In  older  chil- 
dren the  introduction  of  the  finger  high  up  into  the  rectum  may  localize 
on  the  right  an  indurated  mass. 

General  Symptoms. — The  pain  and  tenderness,  however,  which  mark 
the  onset  of  this  disease  commonly  continue  to  be  important  symptoms, 
becoming  rather  less  severe  but  more  constant  in  character.  The  sudden 
cessation  of  pain,  which  is  not  infrequently  associated  with  a  fall  in  tem- 
perature, is  an  ominous  symptom,  especially  when  the  pulse  rate  continues 
rapid  and  the  child's  general  condition  is  not  improved.  This  symptom 
group  means  rupture  of  the  appendix  with  the  relief  of  tension  and  the 
discharge  of  the  infected  material  into  the  periappendicular  region;  this 
accident  is  so  common  that  the  symptom  group  which  marks  it  must  ever 
be  kept  in  mind. 

Constipation,  when  very  aggravated,  is  commonly  associated  with  vom- 
iting, and  this  symptom  group  may  suggest  intestinal  obstruction.  The 
vomiting  is  more  marked  following  rupture  of  the  appendix  and  subse- 
quent involvement  of  the  peritoneum. 

Fever. — A  rise  of  temperature  occurs  early  in  this  disease  and  its 
height  may  mark  the  severity  of  the  process.  This  rule  is  not,  however, 
without  exception,  as  in  rare  instances  cases  of  gangrenous  and  perfora- 
tive appendicitis  may  for  the  first  few  days  run  an  almost  afebrile  course. 
Following  the  rupture  of  the  appendix  and  periappendicular  infection, 
there  is  a  secondary  rise  in  temperature  which  marks  the  progress  of  the 
sepsis  or  peritoneal  inflammation. 

Blood  Examixations. — The  leukocyte  count  is  of  very  great  value 
not  only  in  confirming  the  diagnosis  of  appendicitis,  but  also  in  helping  to 
determine  whether  the  disease  is  progressing  favorably  or  unfavorably.  In 
interpreting  these  blood  counts,  however,  it  should  be  remembered  that  in 
very  young  children  the  proportion  of  lymphocytes  is  much  greater  than 
it  is  in  older  children.  There  is  in  appendicitis,  except  in  the  very  worst 
cases  where  resistance  to  the  infection  is  almost  lost,  a  marked  leukocyto- 
sis of  12,000  to  30,000.  This  increase  in  the  number  of  leukocytes  is 
commonly  in  proportion  to  the  activity  of  the  process;  in  mild  cases  the 
leukocyte  count  may  be  12,000;  in  septic  cases  during  the  acute  stage  it 
may  run  to  30,000.     A  high  leukocyte  count  is  commonly  an  indication 


226  APPENDICITIS 

of  pus.  Daily  blood  examinations  should  be  made  in  all  cases  where  the 
diagnosis  is  doubtful,  or  where  an  operation  for  any  reason  is  postponed; 
an  increasing  leukocyte  count  is  an  unfavorable  sign  and  indicates  progress 
in  the  inflammation ;  a  falling  leukocyte  count  with  other  symptoms  favor- 
able is  a  good  sign,  and  is  an  indication  that  the  child  will  recover  from 
the  present  attack.  A  low  leukocyte  count  occurs  in  fatal  cases  toward  the 
end  of  the  disease,  but  the  low  leukocyte  count  is  here  associated  with 
septic  temperature,  profound  prostration,  a  rapid,  irregular  and  increasing 
pulse  rate,  and  is  an  indication  that  the  vital  powers  of  the  child  are  no 
longer  able  to  call  forth  an  army  of  leukocytes  with  which  to  fight  the 
infection.  A  differential  leukocyte  count  is  also  of  value  in  determining 
the  character  of  the  process.  When  the  polynuclear  leukocytes  are  pres- 
ent in  a  percentage  greater  than  80,  pus  is  probably  present  and  this 
probability  is  greatly  strengthened  if  the  general  leukocyte  count  is  above 
14,000. 

Course. — The  course  of  this  disease  depends  largely  upon  the  severity 
and  character  of  the  inflammation  affecting  the  appendix.  In  the  catarrhal 
form  the  symptoms  previously  noted  may  be  mild  in  their  onset  and  the 
disease  may  run  its  course  within  a  w^eek  or  ten  days,  terminating  in  re- 
covery. In  the  ulcerative  form  the  onset  is  commonly  much  more  severe, 
the  pain,  fever,  vomiting  and  localized  tenderness  being  very  marked  and 
increasing  in  severity,  until,  perhaps  between  the  third  and  fifth  day,  per- 
foration occurs,  producing  a  cessation  of  pain,  fall  in  temperature  and  oth- 
erwise modifying  the  symptom  group  as  previously  noted.  The  subsequent 
history  of  these  cases  depends  upon  whether  a  general  septicopyemia  or  a 
general  peritonitis  follows  the  rupture,  or  whether  the  infectious  material 
is  walled  off  from  the  peritoneal  cavity  by  an  inflammatory  exudate.  In  the 
former  case  the  child  quickly  succumbs  unless  perchance  it  be  saved  by  a 
surgical  operation.  In  the  latter  the  localized  abscess  may  after  a  number 
of  days  begin  to  show  evidences  of  resolution  and  a  slow  convalescence  fol- 
lows, or  it  may  burrow  or  break  into  the  surrounding  tissues  and  place  the 
child's  life  in  immediate  jeopardy.  In  the  gangrenous  form  the  initial 
symptoms  are  even  more  violent  than  in  the  ordinary  perforative  form; 
necrosis  and  general  infection  may  occur  on  the  second  or  third  day  of 
the  disease. 

Diagnosis. — This  disease  may  be  differentiated  from  intestinal  obstruc- 
tion by  the  presence  of  fever,  the  less  severe  pain,  the  absence  of  persistent 
vomiting  and  by  the  presence  of  the  local  symptoms  of  appendicitis  made 
out  by  physical  examination,  and  by  the  absence  of  bloody  mucus  from  the 
intestinal  discharges.  Lobar  pneumonia  of  the  right  lower  lobe  often 
presents  a  picture  closely  resembling  appendicitis;  in  this  condition  there 
may  be  abdominal  distention  and  pain  and  tenderness  in  the  region  of 
the  appendix,  but  the  absence  of  the  other  physical  signs  of  appendicitis, 
with  the  presence  of  the  physical  signs  of  pneumonia,  should  be  sufficient 
to  prevent  this  mistake  in  diagnosis,  provided  the  physician  has  in  mind 
the  fact  that  such  a  symptom  complex  may  be  produced  by  pneumonia. 


TREATMENT  327 

Typhoid  fever  may  be  differentiated  by  the  character  of  the   fever,   the 
presence  of  tlio  Widal  reaction  and  by  the  absence  of  the  intestinal  colic. 

Tuberculosis  of  the  lymphatic  tissues  of  the  appendix  may  produce 
tumor  masses  in  this  region,  which  should  not  be  mistaken  for  appendicitis. 
The  history  and  course  of  the  process  which  produced  the  appendicular 
tumor  in  tuberculosis  is  very  different  from  the  course  of  acute  appen- 
dicitis. 

Prognosis. — The  prognosis  in  private  cases  which  are  seen  early  and 
which  have  the  benefit  of  surgical  interference  at  the  proper  time  is  good; 
more  than  95  per  cent,  of  these  eases  recover.  The  results  that  are  ob- 
tained from  surgical  interference  in  the  suppurative  and  gangrenous  cases 
in  children  are  much  better  than  they  are  in  adults.  The  high  death  rate 
(14  per  cent.)  which  occurs  in  hospital  cases  is  due  to  the  fact  that  they 
do  not  always  have  the  benefit  of  surgical  interference  at  the  proper  time. 

Treatment — The  medical  treatment  demands  that  they  be  kept  abso- 
lutely quiet  in  bed,  with  a  total  abstinence  from  food  for  two  or  three 
days,  but  water  may  be  freely  given.  On  the  third  or  fourth  day  meat 
broths  and  small  quantities  of  whiskey,  well  diluted,  may  be  allowed. 
Cathartics  or  high  rectal  injections  for  the  purpose  of  moving  the  bowels 
are  to  be  avoided  during  the  early  acute  stage  of  this  disease.  A  light  ice- 
bag  placed  for  the  greater  portion  of  the  time  over  the  appendicular  region 
is  a  valuable  remedy;  if  this  produces  discomfort  hot  applications  may  be 
substituted,  especially  in  very  young  children.  Opium  may  be  necessary 
for  the  relief  of  pain,  but  its  use  in  children  is  not  followed  by  the  same 
good  results  seen  in  adults.  When  the  pain  of  this  disease  is  severe 
enough  to  demand  opium  it  is  better  practice  to  refer  the  case  to  the 
surgeon.  On  the  fourtli  or  fifth  day,  with  the  subsidence  of  the  symptoms, 
an  enema  followed  by  a  dose  of  castor  oil  may  be  given,  and  thereafter 
the  child  may  be  allowed  meat  broth,  beef  juice,  albumin  water,  and  later 
milk.  It  should  be  kept  quietly  in  bed  until  convalescence  is  assured ;  re- 
lapses during  this  period  are  especially  dangerous.  Following  an  attack 
the  child  should  be  carefully  fed  within  the  limits  of  its  digestive  capacity, 
violent  exercise  should  not  be  allowed  for  some  months,  constipation 
should  be  carefully  avoided.  These  precautions  are  necessary  to  prevent  a 
second  attack. 

In  the  milder  or  catarrhal  forms  of  appendicitis  it  is  the  duty  of  the 
physician  to  try  to  carry  the  child  through  the  attack  and  refer  it  to  the 
surgeon  for  an  interval  operation;  this  is  much  better  practice  than  oper- 
ating upon  every  case  as  soon  as  a  diagnosis  is  made.  Under  medical  treat- 
ment 95  per  cent,  of  these  cases  recover  from  the  first  attack,  and  this 
mortality  would  not  be  diminished  by  operative  interference  during  the 
attack.  The  treatment  of  the  appendicular  attack  in  the  great  majority 
of  cases  is  purely  medical  and  in  the  handling  of  this  phase  of  the  treat- 
ment the  physician  has  perhaps  more  experience  than  the  surgeon.  During 
the  treatment  of  any  case  of  appendicitis,  however  mild,  the  physician  must 
realize  that  at  any  time  the  case  may  become  a  surgical  one  demanding  im- 


228  PERITONITIS    AND    ASCITES 

mediate  operative  measures.  For  this  reason  the  danger  signals  above 
outlined  must  be  carefully  kept  in  mind.  In  the  more  severe  types  of 
appendicitis,  when  the  initial  symptoms  indicate  that  one  is  in  the  pres- 
ence of  a  suppurative  or  gangrenous  appendicitis,  the  child  should,  in  the 
midst  of  the  attack,  be  referred  to  the  surgeon ;  no  possible  good  can  come 
from  delaying  surgical  interference  in  these  cases,  and  a  difference  of 
twenty-four  or  thirty-six  hours  may  materially  diminish  the  child's  chances 
for  recovery.  Every  well-defined  case  of  appendicitis  should  sooner  or 
later  come  into  the  hands  of  the  surgeon.  The  only  valid  reason  for  post- 
poning indefinitely  surgical  interference  is  that  there  may  have  been  a 
mistake  in  diagnosis;  in  such  cases  one  should  await  the  subsequent  his- 
tory of  the  child  to  confirm  or  deny  the  diagnosis. 


CHAPTER    XXVII 

PERITONITIS    AND    ASCITES 

PERITONITIS 

Etiology. — Appendicitis  is  the  most  common  cause  of  acute  peritonitis, 
and  tuberculosis  is  the  only  cause  of  chronic  peritonitis  in  childhood. 
Acute  peritonitis  from  other  causes,  though  comparatively  infrequent,  is 
met  with  often  enough  to  deserve  careful  consideration. 

The  MICROORGANISMS  most  commonly  associated  with  acute  peritonitis 
are  the  bacterium  coli,  the  streptococcus  pyogenes  and  pyocyaneus,  the 
staphylococcus  aureus,  the  pneumococcus,  the  gonococcus,  the  diploeoccus 
intestinalis,  and  with  the  chronic  form  of  this  disease  the  tubercle  bacillus, 
assisted  in  its  destructive  process  by  streptococci,  staphylococci,  and  other 
organisms.  These  various  microorganisms  are  associated  with  more  or  less 
distinct  types  of  this  disease.  The  bacterium  coli  communis  occurs  espe- 
cially in  the  forms  of  acute  peritonitis  which  have  developed  after  intes- 
tinal perforation.  Streptococci  and  staphylococci  occur  in  the  perfor- 
ative form  and  in  the  septic  types  of  this  disease,  and  also  in  the  forms  of 
peritonitis  that  follow  the  infective  fevers,  such  as  erysipelas,  acute  tonsil- 
litis, diphtheria,  influenza,  scarlet  fever,  and  measles.  Pneumococcus  peri- 
tonitis may  occur  as  one  of  the  localizations  of  a  general  pneumococcus  in- 
fection, or  it  may  spread  from  a  pneumococcus  inflammation  of  tlie  lungs 
and  pleura.  Gonococcus  peritonitis  is  also  almost  always  secondary  to 
gonococcus  vaginitis.  The  gonococci  entering  through  the  uterus  and  fal- 
lopian tubes,  or  in  any  manner  finding  their  way  into  the  pelvic  tissues, 
start  up  there  a  local  inflammation  of  the  pelvic  peritoneum,  which  may  or 
may  not  become  a  general  peritonitis. 

Exciting  Causes. — Appendicitis  is  the  most  important  cause  of  acute 
peritonitis  and  its  exciting  causes  become,  therefore,  the  common  exciting 
causes  of  peritonitis.     Very  rarely  typhoid  fever,  tuberculosis,  and  dysen- 


PERITONITIS  229 

tery  may  cause  perforation  and  produce  peritonitis.  A  perforating  ulcer  of 
the  stomach  and  duodenum  is  one  of  the  rarest  causes.  Suppurative  pro- 
cesses in  the  liver  and  gall-bladder,  strangulated  hernia,  intestinal  obstruc- 
tion, blows  upon  the  abdomen,  perforating  wounds  from  gunshot  injuries 
or  sharp  instruments,  and  operative  measures  in  the  peritoneal  cavity  may 
produce  peritonitis.  The  acute  infectious  diseases  previously  mentioned, 
however,  are  responsible  for  a  majority  of  the  cases  that  cannot  be  traced 
directly  to  appendicitis  or  tuberculosis.  In  the  peritonitis  which  occurs  in 
the  newly  born  infant  the  infection  is  either  a  septic  one  entering  through 
the  umbilicus  or  it  is  due  to  an  enterocolitis  which  furnishes  a  favorable 
opportunity  for  the  infection  of  mesenteric  lymph  nodes  and  later  of  the 
peritoneum. 

Pathology. — The  pathological  process  varies  largely  with  the  character 
of  the  inflammation.  In  all  cases  this  membrane  is  more  or  less  congested 
and  covered  with  a  serous  or  fibrinous  exudate.  In  the  fibrinous  cases  the 
coils  of  the  intestine  and  the  omentum  are  frequently  bound  together  with 
a  fibrinous  exudate  which  greatly  interferes  with  peristalsis.  In  some  cases 
there  is  a  serous  exudation  into  the  peritoneal  cavity,  but  this  is  usually  not 
marked  except  in  the  chronic  tuberculous  form.  Pus  is  found  especially  in 
the  perforative  cases  and  those  due  to  pnemnococcic  infection.  The  pus  in 
the  perforative  cases  has  a  foul  fecal  odor,  is  usually  encapsulated  about 
the  appendix  or  site  of  perforation,  but  it  may  be,  in  the  rapidly  fatal  cases, 
widely  distributed  throughout  the  general  peritoneal  cavity.  The  pus  in  the 
rare  cases  of  pneumococcic  peritonitis  is  very  abundant,  has  no  fecal  odor, 
and  is  usually  walled  off  and  held  by  a  single  large  inflammatory  sac,  which 
has  a  tendency  to  point  toward  the  umbilicus;  spontaneous  perforations  at 
this  point  may  discharge  the  pus  sac  and  result  in  recovery. 

Symptomatology. — The  symptomatology  of  peritonitis  occurring  during 
the  first  days  or  weeks  of  life  is  very  insidious.  The  symptoms  of  sepsis 
or  of  intestinal  irritation  may  be  present  and  almost  entirely  mask  the 
inflammatory  process  going  on  in  the  peritoneum.  Then  perhaps  abdom- 
inal distention  and  tumefaction  lead  to  a  more  careful  physical  examination 
of  the  abdomen,  which  may  be  hard,  tense,  and  give  the  peculiar  resist- 
ance on  palpation  which  is  more  or  less  characteristic  of  inflammation  of 
the  peritoneum.  In  this  way  a  diagnosis  may  be  made  before  the  death 
of  the  infant,  as  this  is  always  a  fatal  disease.  In  many  cases,  however, 
the  diagnosis  is  made  on  the  post-mortem  table.  Peritonitis  occurring  in 
later  infancy  and  childhood  is  a  more  open  and  frank  disease  and  not 
necessarily  a  fatal  one.  Its  onset  depends  largely  upon  the  causative  fac- 
tors. In  appendicitis  a  general  peritonitis  is  announced  by  the  sudden  ces- 
sation of  pain,  fall  in  the  temperature,  increased  rapidity  of  the  pulse,  and 
great  prostration  of  the  patient;  these  symptoms  are  followed,  when  re- 
action occurs,  by  a  rise  in  temperature  and  by  the  appearance  of  the  local 
signs  of  peritonitis.  If  the  condition  be  due  to  a  pneumococcus  infection 
of  the  peritoneum  the  symptoms  are  sudden  in  their  onset  and  general  in 
character,  with  fever,  chill,  headache,  and  all  the  evidences  of  a  general 


230 


PERITONITIS    AND   ASCITES 


pneumococcic  infection  such  as  we  have  in  pneumonia.  ^Vhen  these  symp- 
toms begin  to  subside,  at  the  end  of  five  or  six  days,  abdominal  pain,  dis- 
tention, and  tumefaction  call  unmistakable  attention  to  the  localized  in- 
flammatory process  in  the  peritoneum.     In  this  form  of  the  disease  the 

bowels  are  loose  and 
tlie  abdomen  becomes 
slowly  distended  with 
the  fluctuating  mass 
of  pus,  which  may  be 
outlined  by  palpation 
and  percussion,  and 
which  usually  occu- 
pies the  lower  middle 
portion  of  the  abdo- 
men and  points  to  the 
umbilicus.  In  some  in- 
stances, however,  the 
pus  sac  may  be  in  one 
or  the  other  iliac  re- 
gions, though  com- 
monly pointing  to  the 
umbilicus.  The  onset 
of  gonococcus  perito- 
nitis is  insidious,  oc- 
curring almost  always 
in  girls,  since  it  is 
commonly  preceded  by  a  gonococcus  vaginitis.  The  character  of  the  in- 
flammation in  these  cases  is  for  the  most  part  mild,  spreading  slowly  and 
involving,  as  a  rule,  only  the  pelvic  or  lower  abdominal  peritoneum.  Tlie 
diagnosis  is  made  by  the  presence  of  vaginitis  and  by  the  localized  pain  and 
tumefaction  in  the  lower  abdomen  and  pelvis.  These  cases,  however,  as 
Koplik  says,  are  not  always  benign,  but  may  result  in  a  general  peritonitis 
ending  in  death. 

General  Symptoms. — The  pain  in  peritonitis  is  usually  in  the  right 
iliac  fossa  or  the  umbilical  region  and  from  thence  spreads,  involving  the 
whole  abdomen.  The  patient  lies  on  his  back,  with  his  legs  flexed  on  his 
thighs,  his  abdomen  distended  with  gas  and  tender  to  pressure.  He 
breathes  superficially  and  rapidly,  so  as  not  to  bring  into  play  the  dia- 
phragm or  abdominal  muscles.  He  dreads  being  handled  or  touched;  his 
facial  expression  is  anxious  and  his  whole  attitude  is  that  of  protecting  the 
abdominal  region  from  injury;  his  general  appearance  is  that  of  serious 
illness;  the  body  may  be  hot  and  dry,  the  extremities  cold  and  cyanotic. 
Fever  is  almost  always  present,  but  the  height  of  the  temperature  bears  no 
relationship  to  tlie  seriousness  of  the  disease.  The  pulse  may  range  from 
120  to  130;  it  is  small,  weak,  and  increases  in  rapidity  with  the  downward 
progress  of  the  disease.    Vomiting  is  commonly  present  and  may  be  very 


iiw. 


-Position   in   Acute   Peritonitis. 


PERITONITIS  231 

persistent;  in  the  perforative  cases  its  severity  usually  increases  with  the 
progressive  involvement  of  the  peritoneum.  The  vomited  matter  is  at  first 
food,  then  mucus,  bile,  and,  in  the  more  aggravated  cases,  a  black  coffee- 
ground  material  which  may  have  a  fecal  odor.  Constipation  of  an  aggra- 
vated type  is  the  rule,  but  diarrhea  may  occur,  especially  in  those  cases  that 
follow  the  acute  infections.  With  the  progress  of  the  disease  the  abdomen 
becomes  more  distended  with  gas,  so  that  the  liver  dullness  may  be  obliter- 
ated; general  tumefaction  of  the  whole  abdominal  wall  becomes  more  and 
more  marked,  and  in  septic  cases  the  fever  and  general  symptoms  are  those 
of  a  septicopyemia.    Leukocytosis  is  marked,  especially  in  the  septic  cases. 

Physical  Examination. — The  diagnosis  is  made  by  the  physical  ex- 
amination. The  tenderness  may  be  localized  or  general.  The  abdominal 
resistance  and  induration,  which  are  such  all-important  signs,  may  be  either 
local  or  general,  or  may  begin  from  a  focus  and  spread  gradually  over  the 
entire  abdomen.  By  percussion  or  bimanual  palpation  one  may  localize  the 
exudation. 

Prognosis. — In  the  new-born  the  disease  is  fatal;  in  older  infants  and 
children  the  prognosis  depends  largely  upon  the  character  of  the  inflam- 
matory process.  In  chronic,  tuberculous  peritonitis  the  prognosis  is  good. 
In  gonococcus  peritonitis  a  very  large  per  cent,  of  the  cases  recover  without 
operative  interference.  In  pneumococcus  peritonitis  the  prognosis  is  also 
commonly  good  if  operative  measures  are  resorted  to  at  the  proper  time. 
In  traumatic  peritonitis,  which  is  from  its  inception  a  purely  surgical  con- 
dition, the  prognosis  will  depend  largely  upon  the  severity  of  the  injury 
and  early  operative  interference.  In  perforative  peritonitis  the  prognosis 
has  been  previously  discussed  under  Appendicitis. 

Treatment. — In  the  perforative  forms  of  this  disease,  as  previously 
noted  under  Appendicitis,  the  cases  are  essentially  surgical,  and  as  soon  as 
a  diagnosis  is  made  operative  interference  should  be  resorted  to.  In  the 
milder  traumatic  forms  of  peritonitis,  however,  and  in  those  cases  which  are 
caused  by  acute  infections,  the  medical  treatment  may  be  most  important. 
The  patient  should  be  kept  absolutely  quiet  and  not  be  allowed  to  do  any- 
thing for  himself  that  can  be  done  b}^  others.  Cold  applications  should  be 
applied  to  the  abdomen,  especially  in  the  early  stages  of  the  disease;  later, 
after  four  or  five  days,  when  the  abdomen  is  tender  to  the  touch,  hot  appli- 
cations may  not  only  be  grateful  but  may  be  of  value  in  helping  nature  to 
dispose  of  the  inflammatory  exudate  within. 

The  dietetic  treatment  is  most  important.  For  the  first  two  or  three 
days  absolute  starvation  is  necessary,  water  only  being  allowed;  after  this, 
good  whiskey  or  brandy,  well  diluted,  and  beef  or  mutton  broth  may  be 
given;  the  subsequent  dietetic  treatment  will  depend  upon  the  age  of  the 
child  and  the  extent  of  the  peritoneal  inflammation,  and  should  follow 
along  the  lines  previously  outlined  under  Chronic  Indigestion.  If  after  a 
few  days  the  peritonitis  is  clearly  demonstrated  to  be  of  such  a  character 
that  perforation  of  the  bowels  is  not  to  be  feared,  a  saline  cathartic,  prefer- 
ably sulphate  of  magnesia  or  Eochelle  salts,  should  be  given.    The  thorough 


233  PEKITONITIS    AND    ASCITES 

unloading  of  the  bowels  in  the  non-perforative  cases  is  of  the  very 
greatest  importance  and  materially  assists  in  starting  convalescence.  In 
those  cases,  however,  where  appendicitis  or  typhoid  fever  either  threatens 
or  has  produced  perforation,  cathartics  are  contraindicated.  The  use  of 
opium  may  be  necessary  to  relieve  pain,  but  it  should  be  used  with  great 
discretion,  and  when  perforation  has  occurred  it  is  contraindicated.  The 
best  preparation  of  opium  is  morphin  and  it  should  be  given  hypodermically, 
1-50  of  a  grain  for  a  child  one  year  of  age  and  1-20  of  a  grain  for  a  child 
six  years  of  age,  to  be  repeated  if  necessary.  Enemata  for  unloading  the 
lower  bowel  should  be  employed  in  the  cases  where  they  are  not  contrain- 
dicated by  disease  of  the  large  intestine,  such  as  in  appendicitis.  Gono- 
coccus  peritonitis  is  to  be  treated  by  trying  to  cure  the  causative  vaginitis  (a 
very  difficult  matter)  and  by  general  tonic  treatment,  including  proper 
food,  iron,  cod-liver  oil  and  fresh  air,  and  by  the  local  treatment  above 
noted.  Pneumococcus  peritonitis  is  to  be  treated  by  general  sustaining 
measures,  such  as  are  used  in  pneumonia,  and  later  by  operative  measures 
for  getting  rid  of  the  pus  in  the  abdominal  cavity. 


ASCITES 

Ascites,  or  the  accumulation  of  serum  in  the  peritoneal  cavity,  has  its 
origin  in  children  commonly  in  a  tuberculous  inflammation  of  the  peri- 
toneum. It  may  also  be  caused  by  an  atrophic  cirrhosis  of  the  liver, 
tumors,  enlarged  lymph  nodes  which  obstruct  the  portal  circulation,  dis- 
eases of  the  heart,  producing  a  failure  in  the  general  circulation,  Bright's 
disease,  and  severe  anemia. 

Differential  Diagnosis. — Ascites  from  cardiac  weakness  is  always  asso- 
ciated with  swelling  of  the  legs  and  with  unmistakable  symptoms  pointing 
to  disease  of  either  the  cardiac  valves  or  muscles.  Ascites  from  Bright's 
disease  is  associated  with  a  general  anasarca  and  the  urine  findings  of  that 
disease.  Ascites  from  grave  forms  of  anemia  is  always  associated  with  a 
cachexia,  and  a  blood  examination  establishes  the  diagnosis.  Ascites  from 
local  disturbances  of  the  portal  circulation  may  be  confused  with  tubercu- 
lous peritonitis.  Cirrhosis  of  the  liver  is  rare  in  children  and  is  com- 
monly of  syphilitic  origin.  Other  evidences  of  syphilis  and  the  absence  of 
the  physical  signs  of  peritonitis  usually  suffice  to  make  the  differentiation; 
if  not,  after  the  abdominal  fluid  has  been  removed  by  tapping,  a  contracted 
and  nodular  liver  may  be  demonstrated,  or,  failing  in  this,  the  negative  tu- 
berculin skin  reactions  may  throw  light  on  the  subject.  Tumors  and  en- 
larged lymph  nodes  (tuberculous)  of  sufficient  size  to  produce  ascites  by 
obstructing  the  portal  circulation  can,  as  a  rule,  be  demonstrated  by  palpa- 
tion after  removal  of  the  serum.  In  the  presence  of  a  marked  ascites  in 
children  the  physician  should  remember  that  tuberculosis  is  the  common 
cause  of  this  condition,  and  that  often  the  abdominal  cavity  in  this  disease 
may  be  distended  with  serum  without  any  very  acute  symptoms;  there  may 


MALFORMATIONS  OF  EECTUM  AND  ANUS  233 

be  very  little  tenderness  and  induration  of  the  abdominal  wall  and  the 
condition  may  have  developed  very  insidiously.  For  these  reasons  ascites 
due  to  a  low  grade  of  chronic  tuberculosis  is  very  commonly  suspected  to  be 
due  to  other  causes.  The  importance,  therefore,  of  making  a  thorough 
examination  for  every  sign  or  symptom  of  tuberculosis  cannot  be  exagger- 
ated.    . 


CHAPTER  XXVIII 
THE   EECTUM    AND    ANUS 

MALFORMATIONS  OF  RECTUM  AND  ANUS 

Complete  or  partial  congenital  occlusion  of  the  rectum  or  anus  may 
occur.  Atresia  of  the  anus  may  result  from  the  failure  to  absorb  the  skin 
covering,  which  normally  guards  the  rectum  during  intrauterine  life.  This 
condition  may  usually  be  made  out  a  few  hours  after  birth  by  the  bulging 
of  the  rectum  beneath  the  skin,  and  a  slight  exploratory  incision  discovers 
the  rectum  and  cures  the  deformity.     Atresia  of  the  rectum  is  a  more  seri- 


FiG.  38. — Malformations  of  the  Rectum. 

ous  matter;  in  this  condition  the  occlusion  of  the  rectum  is  commonly 
located  two  or  three  inches  from  the  anus.  In  some  instances  the  anal 
end  of  the  rectum  below  the  occlusion  is  patulous  and  continuous  with  a 
patulous  anus;  in  such  cases  the  exploring  finger  introduced  through  the 
anus  into  the  rectum  may  readily  reach  the  septum  and  direct  the  trochar 
which  relieves  the  obstruction  by  puncturing  this  septum.  In  another 
group  of  cases  there  is  congenital  absence  of  the  rectum  below  the  point  of 
occlusion.  The  blind  sac  of  the  rectum,  some  inches  from  the  anus,  is 
connected  with  it  by  an  impervious  cord,  which  represents  the  undeveloped 
rectum.  In  some  of  these  cases  the  contents  of  the  rectal  pouch  find  their 
way  by  fistulous  trficts  through  the  peritoneum  or  into  the  bladder,  vagina, 
or  urethra.  In  those  cases  where  occlusion  is  complete  immediate  sur- 
gical measures  are  necessary.  In  other  cases,  however,  where  the  fistulous 
tracts  are  wide  enough  to  serve  the  temporary  purpose  of  emptying  the 


234  THE  RECTUM   AND  ANUS 

rectal  pouch,  a  surgical  operation  may  be  postponed  for  a  short  time  until 
the  infant  is  stronger. 

POLYPUS  OF  THE  RECTUM 

Polypus  of  the  rectum  is  not  infrequent  in  children ;  the  tumor  is  at- 
tached by  a  pedicle  to  the  rectal  wall  and  is  usually  single,  but  occasionally 
more  than  one  tumor  is  present.  It  may  exist  for  a  long  time  without 
presenting  itself  at  the  rectum  and  during  this  time  there  may  be  more  or 
less  rectal  irritation,  with  tenesmus  and  blood  and  mucus  in  the  stools. 
The  diagnosis  may  be  made  by  introducing  the  finger  into  the  rectum;  in 
this  way  the  tumor  may  very  readily  be  outlined  and  differentiated  from 
hemorrhoids  and  intussusception.  A  rectal  examination  should  be  made  in 
all  cases  in  which  there  is  an  unexplained  hemorrhage  from  the  rectum. 

Treatment. — Rectal  polypi  may  easily  be  removed  by  twisting  the  pedi- 
cle with  forceps  or  with  a  wire  snare.  Following  their  removal,  the  rectal 
irritation  rapidly  subsides  and  the  growth  does  not  commonly  recur. 

PROLAPSE  OF  THE  RECTUM 

This  condition  is  usually  seen  in  children  under  six  months  of  age; 
the  almost  straight  rectum,  with  its  weak  attachments  at  this  period  of 
life,  predisposes  to  prolapse.  It  occurs  more  commonly  in  malnourished 
children  suifering  from  diarrhea  and  constipation.  Rectal,  vesicle,  or 
genital  irritation  produced  by  thread-worms,  fecal  concretions,  rectal  polypi, 
vesicle  calculi,  cystitis,  urethritis,  and  phimosis  may  be  factors  in  pro- 
ducing it.  In  mild  cases  the  mucous  membrane  of  the  anus  may  be  but 
slightly  everted  when  the  bowels  are  moved  and  the  blood  and  mucus  may 
appear  upon  the  napkin.  In  more  severe  cases  the  rectal  wall  may  be 
prolapsed,  forming  a  dark-red  corrugated  tumor  two  or  three  inches  long, 
which  bleeds  readily  on  manipulation ;  at  the  end  of  this  tumor  a  depression 
marks  the  anal  opening.  The  prolapsed  rectum  can,  as  a  rule,  easily  be 
replaced  by  gentle  pressure,  the  prolapse  recurring  again  when  the  bowels 
are  moved.  In  rare  instances  the  tumor  remains  down  and  cannot  be  re- 
placed by  simple  manipulation ;  in  such  cases  the  parts  may  bleed,  become 
much  swollen  and  inflamed,  and  strangulation  and  ulceration  of  the  mu- 
cosa may  occur. 

Treatment. — The  reduction  of  the  tumor  mass  is  commonly  easily 
accomplished  by  manipulating  it  gently  upward  through  a  cold,  moist 
towel;  if  difficulty  is  experienced  in  reducing  the  tumor  the  child  should 
be  plaeed  in  bed,  stomach  downward,  and  cold  compresses  applied  to  the 
part.  Following  these  applications,  the  tumor  may  be  easily  reduced;  if 
not,  a  few  inhalations  of  chloroform  will  relieve  the  contracted  muscles 
and  make  the  reduction  of  the  prolapsed  rectum  an  easy  matter.  The 
rectum  having  been  returned  to  its  normal  position,  the  object  of  all  sub- 
sequent treatment  is  to  keep  it  there.     In  order  to  accomplish  this  it  is 


FISSURE    OF   THE    ANTJS  235 

advisable  to  keep  the  child  in  bed,  or  at  least  in  a  reclining  posture,  until 
all  local  irritation  of  the  rectal  mucous  membrane  has  been  removed.  Pin- 
worms  and  colitis,  if  they  exist,  are  to  receive  prompt  attention.  If  phi- 
mosis be  present  the  infant  is  to  be  circumcised,  as  the  reflex  irritation 
from  the  genital  organs  ma}'  be  an  important  factor  in  producing  subse- 
quent attacks  of  prolapse.  The  rectum  may  be  retained  in  position  by 
strapping  the  buttocks  with  adhesive  plaster  when  the  child  is  on  its  feet 
and  by  having  the  child  lie  down  before  every  movement  of  its  bowels. 
Following  the  evacuation  of  the  bowels,  a  large  injection  of  cold,  normal 
salt  solution  should  be  given;  these  cold  injections  are  of  great  value  in 
the  treatment.  In  still  more  severe  cases  the  thermo-cautery  may  be  used 
on  the  prolapsed  mucous  membrane,  making  a  number  of  linear  cicatrices 
in  a  longitudinal  direction.  In  rare  instances  amputation  of  the  tumor 
may  be  necessary;  this  operation  is  usually  attended  with  success. 

FISSURE  OF  THE  ANUS 

This  condition  is  not  uncommon;  it  is  produced  by  constipation;  the 
passage  of  large,  hard,  fecal  masses  stretches  and  tears  the  mucous  mem- 
brane about  the  anus.  Infection  may  follow  this  injury  and  a  small  fissured 
ulcer  may  form,  coated  with  pus  and  mucus  and  imbedded  in  the  folds  of 
the  mucous  membrane,  which  is  more  tightly  grasped  by  the  sphincter  ani, 
because  of  the  irritation  produced  by  the  fissure.  Fischl  says  that  fissures 
of  the  anus  occur  almost  exclusively  on  the  posterior  rectal  wall,  and  that 
they  can  be  seen  only  by  placing  the  child  upon  its  back,  with  its  pelvis 
elevated  and  legs  widely  separated  and  flexed  on  the  trunk ;  in  this  position, 
with  fingers  on  either  side  of  the  anus,  pressing  it  apart,  the  fissure  is 
exposed.  The  condition  may  be  complicated  or  even  produced  by  the  pres- 
ence of  pin  worms,  the  parts  being  torn  by  scratching.  These  ulcers  are 
extremely  painful  when  they  are  touched  or  when  the  rectum  is  manipulated 
in  any  way.  Defecation  is  resisted  by  the  child  and,  when  it  can  no  longer 
be  postponed,  causes  great  pain.  The  chronic  constipation  which  is  so  com- 
monly the  cause  of  this  condition  is  still  further  aggravated  by  its  presence, 
the  powerfully  contracted  sphincter  resisting  the  passage  of  fecal  masses. 
There  is  little  tendency  to  spontaneous  recovery.  So  great  is  the  pain 
produced  by  defecation  in  some  of  these  cases  that  retention  of  urine  occurs 
as  a  result  of  the  child's  dread  of  bringing  into  action  the  muscles  of  the 
bladder,  which  are  so  closely  associated  physiologically  with  the  muscles  of 
the  rectum. 

Treatment. — The  constipation  should  be  relieved  by  laxative  medicines, 
such  as  compound  licorice  powder  for  children  and  milk  of  magnesia  for 
infants.  In  mild  cases  the  fissure  should  be  treated  daily  by  carefully 
cleansing  with  a  cotton-wrapped  pfobe  and  then  touching  it  with  a  2-per 
cent,  solution  of  cocain  muriate,  following  this  by  the  application  of  a 
10-per  cent,  solution  of  nitrate  of  silver.  Under  this  treatment  mild  cases 
recover.     The  strength  of  the  silver  nitrate  solution  must  be  regulated  by 


236  THE  RECTUM   AND  ANUS 

the  pain  and  discomfort  which  follow  its  use.  More  severe  cases  are  to  be 
treated  surgically;  these  usually  get  well  following  thorough  dilatation 
and  stretching  of  the  sphincter  under  complete  anesthesia. 

SPASM  OF  THE  ANUS 

This  condition  is  commonly  due  to  fissure;  it  may  occur  in  neurotic 
children  from  causes  which  produce  irritation  of  the  rectal  mucous  mem- 
brane; it  produces  constipation,  tenesmus,  and  pain  on  defecation.  For 
the  relief  of  this  condition  mild  laxatives  are  indicated;  warm  olive  oil 
injected  into  the  rectum  may  be  of  value.  If  these  means  fail,  forcible 
dilatation  of  the  sphincter  muscle  should  be  resorted  to, 

PROCTITIS 

Proctitis,  or  inflammation  of  the  rectum,  may  exist  unassociated  with 
catarrhal  conditions  of  other  portions  of  the  intestinal  mucous  membrane. 
It  may  be  produced  by  thread  worms,  by  the  frequent  use  of  glycerin,  soap, 
and  other  irritating  suppositories,  by  the  careless  use  of  the  thermometer, 
by  rectal  tubes  used  in  giving  enemata,  or  it  may  be  a  complication  of 
vulvovaginitis.  It  is  characterized  by  tenesmus,  constipation,  painful  de- 
fecation, and  a  discharge  of  pus  and  blood  associated  with  tenesmus.  It 
may  be  relieved  by  mild  cathartics  and  rectal  injections  of  saline  solutions 
or  olive  oil.  Occasionally  mild  astringent  solutions  of  one-half  per  cent, 
of  nitrate  of  silver  are  indicated. 


SECTION   V 

NUTRITIONAL  DISORDERS 

CHAPTER   XXIX 

EICKETS 
(Rachitis) 

Rickets  is  a  chronic  disease  characterized  by  nutritional  disorders,  and 
consequent  lack  of  development  and  perverted  function  on  the  part  of 
nearly  every  organ  and  tissue  of  the  body.  It  affects  chiefly  the  bones, 
nervous  system,  muscles,  mucous  membranes,  ligaments,  and  blood,  and 
is  believed  to  be  largely  a  disturbance  of  calcium  metabolism. 

Etiology. — Rickets  is  a  disease  of  infancy;  more  than  80  per  cent,  of 
the  cases  occur  under  two  years  of  age;  it  rarely  begins  during  the  first 
three  months  and  is  unusual  after  the  third  year.  It  is  a  very  common 
and  widespread  disease;  in  our  largest  cities  perhaps  90  per  cent,  of  the 
infants  of  the  poor  show  some  signs  of  rickets.  It  is,  however,  much  more 
common  in  cities  than  it  is  in  the  country,  because  a  greater  percentage  of 
country  children  are  breast-fed,  live  under  better  hygienic  conditions,  spend 
a  greater  portion  of  their  time  in  the  open  air,  and  are  altogether  better 
fed.     Heredity  is  an  important  factor. 

Rickets  occurs  more  commonly  in  cold  than  in  warm  climates.  This  is 
due  not  so  much  to  climate  as  it  is  to  the  conditions  of  life  which  cold 
climates  force  upon  a  poverty-stricken  population.  Impure  air  and  lack  of 
sunshine  are  very  important  causative  factors  which  act  largely  through 
the  unfavorable  influence  they  exert  on  the  child's  digestive  capacity. 

Faulty  feeding  is  the  most  important  cause  of  rickets.  This  disease 
rarely  occurs  in  breast-fed  babies,  unless  lactation  is  prolonged  or  the 
mother's  milk,  by  reason  of  her  vocation  or  ill  health,  furnishes  insuffi- 
cient nutrition  to  the  rapidly  growing  infant.  It  is,  however,  very  com- 
mon among  artificially  fed  infants  who  are  insufficiently  nourished  on  im- 
proper food  formulas.  A  marked  excess  of  carbohydrates  and  a  notable 
deficiency  in  fat,  protein  and  salts  are  the  special  dietetic  errors  most  closely 
related  to  the  etiology  of  rickets.  This  is  the  reason  condensed  milk,  N"es- 
tle's  food,  malted  milk,  and  other  proprietary  foods  which  do  not  require 
fresh  milk  in  their  preparation,  are  such  potent  factors  in  producing  rickets. 

237 


238 


EICKETS 


It  is  a  well-founded  belief  that  a  deficiency  of  fat  in  the  infant's  food  is  the 
most  important  of  tlu'so  dietetic  errors  and  is  most  commonly  related  to 
the  etiology  of  rickets.  The  absence  of  fat  interferes  with  the  proper 
assimilation  of  lime  and  pliosphorus  and  this,  perhaps,  explains  the  potency 
of  fat  starvation  as  an  etiological  factor  of  this  disease.  The  prevalence  of 
rickets  among  the  negroes  and  Italians  of  our  large  cities  is  not  due  to 
racial  or  hereditary  influences,  but  is  purely  a  question  of  bad  hygiene  and 
improper  food. 

Pathology  and  Morbid  Anatomy.— At  the  junction  of  epiphysis  and 
diaphysis  the  ribs  and  long  bones  are  enlarged  by  a  proliferation  of  poorly 
constructed  vascular  cartilaginous  and  bony  tissue  between  the  epiphyseal 


Fig.  39. — Bony  Deformities  in  Rickets.     (A.  Freiberg.) 


cartilage  and  the  cancellous  portion  of  the  diaphysis.  Bony  structures 
everywhere,  and  especially  the  long  bones,  are  more  vascular  and  cancellous 
than  normal,  and  there  is  increased  resorption  of  bone;  the  subperiosteal 
calcification  and  formation  of  new  bony  tissue  is  interfered  with.  Such 
bones  contain  only  one-third  instead  of  the  two-thirds  mineral  matter  which 
normal  bones  contain.  These  changes  produce  an  increased  flexibility  of 
the  bones  which  predisposes  the  infant  to  the  deformities  so  characteristic 
of  rickets. 

Muscular  tissue  is  everywhere  poorly  formed,  and  the  muscular  fibers 
are  infiltrated  with  fat  and  may  show  partial  fatty  degeneration.  The 
muscles  are  poorly  nourished,  weak,  flabby,  easily  stretched,  and  offer  an 


SYMPTOMATOLOGY 


239 


insufficient  support  to  the  viscera  and  bones  which  they  cover.  The  liga- 
ments are  weak,  flabby,  easily  stretched,  and  do  not  properly  sustain  the 
bony  structures. 

The  spleen  is  notably  enlarged,  it  is  anemic,  its  Malpighian  bodies  are 
atrophied  and  its  function  as  a  blood-forming  organ  is  interfered  with. 
The  lymph  nodes  are  slightly  enlarged.  The  liver  is  somewhat  increased 
in  size  and  displaced  downward. 

Symptomatology. — Rickets  is  a  chronic  malnutrition  affecting  every 
part  of  the  body.  The  bony  lesions  are  the  most  pronounced,  the  most 
characteristic,  and  the  most  easily  recognized,  but  they  are  not  the  earliest 
nor  are  they  the  most  important 
signs  of  this  disease.  A  general 
failure  of  nutrition,  manifested 
by  the  following  symptom 
group,  presents  the  syndrome 
upon  which  the  diagnosis  is 
made;  retardation  in  physical 
develoi)ment ;  muscular  weak- 
ness; inability  to  sit  erect,  to 
hold  the  head  up,  or  to  use  the 
legs  in  a  normal  manner; 
flabby  and  undeveloped  mus- 
cles; marked  anemia;  general 
nervous  irritability;  scarcity  of 
hair  on  the  back  of  the  head 
due  to  restlessness  and  head 
sweating  when  asleep;  tendency 
to  fever  from  slight  causes ; 
late  teething;  a  large,  square, 
flat  head  with  open  fontanels; 
a  chest  contracted  above  and 
constricted  transversely  at  the 
diaphragmatic  attachment;  flar- 
ing ribs  below  the  diaphragm, 

turned  upward  upon  a  markedly  distended  abdomen;  a  rickety  rosary  of 
bead-like  prominences  at  the  junction  of  the  ribs  with  the  costal  cartilages ; 
knob-like  prominences  of  the  bones  just  above  the  ankles  and  wrists;  con- 
stipation; a  tendency  to  gastrointestinal  disturbances  and  bronchial  ca- 
tarrh; large  belly;  enlarged  spleen  and  a  liver  protruding  below  the  costal 
margin.  In  the  more  severe  forms  of  rickets  the  above  symptoms  are  much 
exaggerated  and  the  deformities  which  result  from  diseased  viscera,  weak 
ligaments,  ill-developed  muscles,  and  flexible  bones,  are  very  great. 

General  Appeaeance. — Eachitic  babies  in  the  early  stages  may  be  fat 

and  flabby,  so  that  to  the  prejudiced  eye  of  the  mother  they  may  appear 

normal,  while  to  the  practiced  eye  of  the  physician  they  present  at  a  glance 

the  characteristic  signs  of  rickets.     As  the  disease  advances,  however,  they 

17 


Fig.  40. — Rickets. 


240  EICKETS 

become  emaciated  and  then  the  thin,  old  face,  large,  square  head,  resting 
on  a  narrow,  contracted,  dofornied  chest,  the  large,  distended  abdomen,  the 
crooked  back,  the  thin,  bent,  and  deformed  arms  and  legs  present  the  char- 
acteristic picture  of  advanced  rickets  with  which  even  the  laity  are  familiar. 

General  Sy^iptoms. — Head  sweating  when  the  infant  sleeps  is  one  of 
the  early  significant  symptoms  and  should  lead  to  a  search  for  other  signs 
of  rickets.  Delayed  and  difficult  dentition  is  an  almost  constant  accom- 
paniment of  even  the  mild  forms  of  rickets.  In  a  normal  infant  a  tooth 
may  come  through  with  little  or  no  constitutional  disturbance,  but  in  a 
rachitic  child  it  commonly  produces  fever,  sleeplessness,  general  nervous 
irritability,  and  some  slight  gastrointestinal  disturbance.  In  fact,  the 
severity  of  these  symptoms,  on  the  cutting  of  a  tooth,  may  be  an  important 
indication  not  only  of  the  presence  of  rickets,  but  of  the  severity  of  the 
nutritional  disturbances  which  it  has  produced  in  the  nervous  system.  The 
teeth  of  the  rachitic  infant  are  poorly  formed  and  decay  early. 

Kervous  symptoms  are  of  great  value  in  the  early  diagnosis  of  rickets. 
Rachitic  children  are  fretful  and  nervous,  poor  sleepers,  toss  restlessly  in 
their  sleep,  and,  as  a  result,  very  commonly  have  an  occipital  baldness.  Re- 
flex and  toxic  agents  have  a  highly  exaggerated  influence  on  their  nervous 
systems;  slight  reflex  and  toxic  factors  in  the  intestine  and  elsewhere  pro- 
duce high  fever  and  convulsive  symptoms.  The  predisposition  of  the 
rachitic  infant  to  fever  and  convulsive  disorders  occurs  early  and  may  be 
an  aid  to  an  early  diagnosis;  convulsions  or  fever  occurring  in  an  infant 
from  a  trivial  or  from  no  apparent  exciting  cause  should  lead  to  a  careful 
search  for  other  signs  of  rickets.  Laryngismus  stridulus  and  tetany  are 
nervous  syndromes,  very  closely  associated  with  the  more  advanced  and 
severe  types  of  rickets.  Spasmophilia,  or  exaggerated  peripheral  nerve 
excitability,  is  one  of  the  most  characteristic  phenomena  seen  in  rachitic 
children. 

Gastrointestinal  disorders  occur  very  commonly  and  very  early  in  most 
cases  of  rickets;  in  this  disease  there  is  a  predisposition  to  catarrhal  dis- 
eases which  may  be  especially  marked  on  the  part  of  the  gastrointestinal 
tract.  In  some  instances  the  gastrointestinal  disturbances  precede  the 
rickets  and  may  be  considered  as  causative  factors.  The  pot-belly  of  rickets, 
which  develops  early,  is  an  important  symptom  and  is  associated  with  fre- 
quent attacks  of  indigestion  and  intestinal  fermentation;  in  this  condition 
the  abdominal  muscles  are  relaxed,  flabby,  and  greatly  distended  by  the 
flatulent  intestines.  The  enlarged  spleen  and  the  downward  displacement 
of  the  liver  can  easily  be  made  out  by  palpation  and  percussion. 

Hernias,  both  inguinal  and  umbilical,  are  very  frequently  seen  in 
rachitic  infants;  in  fact,  rickets  is  the  most  common  predisposing  cause  of 
infantile  hernias.  The  recti  muscles  are  sometimes  separated  as  much  as 
an  inch  by  abdominal  distention. 

Weak  ligaments  and  muscles  are  always  present  and  are  largely  respon- 
sible for  the  helplessness  or  physical  backwardness  of  the  rachitic  infant ; 
the  curvature  of  the  spine  and  the  tardiness  of  the  infant  in  sitting,  stand- 


SYMPTOMATOLOGY 


241 


ing,  walking,  and  in  making  all  the  complicated  muscular  movements  are 
largely  due  to  this  cause. 

Bony  deformities  are  the  most  characteristic  and  easily  recognized  signs 
of  rickets;  some  of  these  occur  early  in  the  disease.  The  beading  of  the 
ribs,  or  rickety  rosary,  the  horizontal  depression  of  the  ribs  at  the  dia- 
phragmatic attachment  and  their  flaring  upwards  below  this  line,  the 
marked  enlargement  of  the  long  bones  just  above  the  wrist  and  ankle  may 
be  counted  among  the  bony  changes  which  are  of  great  value  in  the  early 
diagnosis  of  rickets. 
As  the  disease  ad- 
vances the  bony  de- 
formities are  more 
exaggerated ;  the  soft 
vertebrae,  with  tlieir 
relaxed  ligaments 
and  weak  muscular 
support,  result  in 
gradually  increasing 
curvatures  of  the 
spine ;  the  posterior 
curvature  (kyphosis) 
is  the  most  charac- 
teristic and  common- 
ly involves  all  the 
lower  portion  of  the 
spine  below  the  mid- 
dorsal  region;  exten- 
sive lateral  curva- 
tures are  also  com- 
mon ;  rotary  curva- 
tures are  also  noted. 
Eachitic  curvatures 
are  not  as  sharp  and 
angular  as  those  due 
to  tuberculous  dis- 
ease   and    they    are 

not,  especially  in  their  earlier  stages,  fixed;  they  will,  as  a  rule, 
entirely  disappear  when  proper  pressure  and  extension  is  applied.  The 
clavicle  may  be  curved  upward  and  forward  in  its  inner  third.  In 
severe  cases  the  pelvis  is  permanently  deformed,  small,  and  especially 
contracted  in  its  anteroposterior  diameter.  The  arms  and  legs  may 
be  greatly  deformed  by  the  curving  and  twisting  of  long  bones;  the  hu- 
merus may  be  curved  outward  and  the  natural  outward  curve  of  the  radius 
and  ulna  may  be  exaggerated.  In  the  lower  extremities  the  most  common 
deformity  is  an  outward  curvature  of  the  lower  third  of  the  tibia,  producing 
"bow  legs" ;  we  may  also,  much  less  frequently,  have  "knock-knees,"  which 


Fig.  41. — Knock-knees  and  Bow-legs  Due  to  Rickets  in 

A    SiSTEB    AND    BROTHER,    AGED    FiVE    AND    ThREB. 


242  EICKETS 

Holt  says  "are  more  common  in  females  and  are  believed  to  be  due  to  an 
overgrowth  of  the  inner  condyles  of  the  femur."  The  cranium  presents 
some  of  the  most  important  characteristic  bony  deformities.  The  head  is 
larger  than  normal  and  the  anterior  fontanel  is  much  delayed  in  closing; 
at  one  year  of  age  it  may  measure  from  IVo  to  21/2  inches  in  both  diameters, 
while  at  this  time  it  should  not  measure  more  than  1/2  or  1  inch;  it  may 
remain  open  to  the  end  of  the  third  year.  The  top  of  the  head  presents  a 
flattened,  square  appearance  due  to  thickening  of  parietal  and  frontal  emi- 
nences. In  young  infants  soft  and  yielding  spots,  due  to  thinning  of  the 
bone  in  the  parietal  and  occipital  regions,  are  found ;  these  patches  may  be 
from  1/2  to  1  inch  in  diameter.  This  condition,  known  as  craniotabes,  is 
not  more  characteristic  of  rickets  than  it  is  of  syphilis;  it  occurs  in  both 
conditions  and  is  very  commonly  associated  with  the  syndrome  of  laryngis- 
mus stridulus. 

Blood  Changes. — According  to  Morse,  a  number  of  forms  of  anemia 
may  occur,  the  red  cells  are  slightly  reduced,  and  the  hemoglobin  very 
much  so,  from  30  to  40  per  cent.  The  specific  gravity  is  reduced  and 
leukocytosis  is  present  when  the  spleen  is  markedly  enlarged. 

The  mucous  membranes  of  rachitic  infants  are  especially  prone  to  catar- 
rhal inflammations  from  slight  causes.  Gastrointestinal  catarrh,  coryza, 
pharyngitis,  laryngitis,  bronchitis,  and  pneumonia  are  common  complica- 
tions of  rickets. 

Course. — Eickets  is  a  chronic  disease  and  its  duration  will  depend  on 
its  severity  and  the  character  of  the  treatment  instituted.  In  mild  cases, 
under  proper  treatment,  it  may  be  cured  in  three  or  four  months.  In  severe 
cases  the  active  symptoms  may  last  from  eighteen  months  to  two  years. 
Many  of  the  rachitic  deformities  are  permanent. 

Congenital  rickets  is  a  rare  disease.  It  does,  however,  occur  in 
utero ;  infants  are  born  with  craniotabes,  the  rickety  rosary,  and  other  char- 
acteristic bony  changes;  this  form  of  the  disease  is  especially  rare  in 
America. 

Late  rickets,  occurring  in  children  from  six  to  ten  years  of  age,  is 
very  uncommon.  In  these  cases  the  bony  deformities  develop  rapidly.  I 
have  seen  but  one  case,  a  girl  seven  years  of  age  in  whom  there  rapidly  de- 
veloped a  softening  and  bending  of  the  bones  of  the  legs  and  other  charac- 
teristic symptoms.  Braces  were  applied  and  treatment  instituted.  The 
child  recovered  after  ten  or  twelve  months'  treatment. 

Diagnosis. — The  diagnosis  of  well-marked  rickets  is  easily  made  and 
attention  will  only  be  directed  to  the  fact  that  it  should  be  made  in  most 
cases  much  earlier  than  it  is.  If  nervous,  irritable  children,  who  have  been 
fed  on  a  food  rich  in  starch  and  poor  in  fat  and  protein,  show  general  lack 
of  development,  late  teething,  open  fontanels,  muscular  weakness,  and  head 
sweating  during  sleep,  a  diagnosis  of  rickets  should  be  made  without  wait- 
ing for  the  disease  to  proclaim  itself  by  its  more  characteristic  symptoms. 

Prognosis. — The  prognosis  in  cases  of  mild  rickets  is  very  good;  the 
disease,  in  this  stage,  contributes  little  or  nothing  to  the  mortality  list. 


TREATMENT  243 

Severe  rickets,  however,  is  a  very  grave  disease  and  contributes  largely  to 
the  death  list  in  our  large  cities;  not  that  rickets  itself  is  so  dangerous,  but 
it  reduces  the  vitality  of  the  infant  to  such  a  low  ebb  that  it  readily  suc- 
cumbs to  catarrhal  diseases  of  the  gastrointestinal  and  respiratory  tracts,  as 
well  as  to  convulsive  disorders  which  are  such  common  complications  of  rickets. 

Treatment. — Prophylaxis. — Since  rickets  is  such  a  common  disorder 
in  artificially  fed  infants,  and  since  the  disease  can,  as  a  rule,  be  prevented 
by  careful  feeding  and  proper  hygiene,  the  physician  should  have  in  mind 
the  prophylactic  treatment  of  rickets  in  the  feeding  of  every  baby  that 
comes  under  his  care.  In  breast-fed  babies  the  prophylactic  treatment  of 
infants  is  not,  as  a  rule,  difficult ;  it  is  only  necessary  to  be  sure  that  they 
have  a  sufficient  amount  of  good  breast  milk,  and,  where  there  is  any  doubt 
upon  this  question,  to  supplement  the  breast  feedings  with  properly  modi- 
fied fresh  cow's  milk,  according  to  the  rules  outlined  under  Mixed  Feed- 
ing. If  the  breast  milk  is  sufficient  and  of  proper  quality,  it  is  safest  to 
continue  to  feed  the  baby  exclusively  on  breast  milk  for  nine  months  and 
then  to  supplement  the  breast  feedings  with  fresh,  clean  cow's  milk.  In 
artificially  fed  infants,  however,  the  problem  is  a  very  different  one.  It  is 
easy  enough  to  write  out  a  milk  formula  for  an  infant  with  normal  digestive 
capacity  which  will  furnish  it  with  the  proper  number  of  calories  and  with 
the  proper  percentages  of  fat,  protein,  salts,  and  carbohydrates  to  prevent 
the  development  of  rickets.  But  there  are  other  infants,  born  of  delicate 
parentage,  suffering  from  mild  forms  of  glandular  tuberculosis  or  other 
constitutional  diseases;  premature  infants  and  infants  who  because  of  gas- 
trointestinal disorders  have  a  feeble  digestive  capacity;  these  are  the  cases 
that  give  us  trouble  and  that  force  us  to  a  compromise  which  results  in  a 
food  formula  which  the  infant  can  digest,  but  which  may  fail  to  fully 
supply  its  nutritional  demands.  In  these  cases  it  is  difficult  for  even  the 
most  experienced  physician  to  carry  the  infant  through  the  first  year  with- 
out the  development  of  at  least  a  mild  form  of  rickets,  unless  a  wet-nurse 
is  employed. 

Curative  Treatment. — From  what  has  been  said  it  is  clear  that  the 
important  factor  in  the  treatment  of  rickets  is  the  diet.  The  disease  has 
developed  upon  a  food  formula  which  failed  to  meet  nutritional  demands, 
and  this  formula  is  commonly  rich  in  carbohydrates  and  poor  in  fat,  pro- 
tein, and  salts,  such  as  we  find  in  condensed  milk,  Nestle's  food,  malted 
milk,  and  other  proprietary  foods  which  do  not  require  fresh  cow's  milk  in 
their  preparation.  It  follows,  therefore,  that  it  is  absolutely  necessary  to 
success  in  the  treatment  of  rickets,  that  the  food  upon  which  the  infant  has 
developed  the  disease  should  be  either  radically  changed  or  greatly  modi- 
fied. A  mistake,  however,  which  is  very  common  and  which,  as  a  rule,  is 
fraught  with  disastrous  results  is  a  too  radical  change  in  the  diet.  Many 
rachitic  infants,  when  they  come  under  the  observation  of  the  physician, 
have  for  a  long  time  been  fed  upon  one  of  the  easily  digested  proprietary 
foods  and  have,  therefore,  such  feeble  digestive  capacity  that  they  cannot 
at  once  be  placed  upon  cow's  milk.     If  such  a  radical  change  is  attempted 


244  RICKETS 

ill  these  cases  it  is  probable  that  gastrointestinal  disturbances  will  be  added 
to  the  other  rachitic  symptoms.  It  is  necessary,  therefore,  in  changing  the 
food,  especially  of  infants  with  advanced  rickets,  to  make  haste  slowly.  One 
may.  perhaps,  in  these  cases  begin  by  adding  skimmed  raw  milk  to  the  food 
the  infant  is  already  taking  and  gradually  increasing  the  milk  so  as  to 
develop  the  digestive  capacity.  In  this  way  the  original  proprietary  food 
mixture  may  be  gradually  replaced  by  skimmed  milk  and  later  by  whole 
milk,  until  a  food  formula  is  reached  which  in  fat  and  proteins  will  serve 
the  nutritional  demands  of  the  infant.  It  may  be  necessary  in  some  in- 
stances to  use  peptonized  milk  to  gradually  replace  the  proprietary  food  and 
then  later  to  gradually  diminish  the  peptonization  until  the  baby  is  on  a 
suitable  raw-milk  formula.  If  the  infant  has  developed  rickets  on  steril- 
ized milk  this  food  must  be  replaced  by  raw  milk.  By  this  gradual  process 
of  eliminating  an  unsuitable  food  the  child  may  be  placed  upon  a  proper 
food  mixture  without  producing  digestive  disturbances.  The  object  in 
every  instance  being  to  increase  the  proteins,  fat,  and  salts  and  diminish  the 
carbohydrates,  but  in  doing  this  great  care  must  be  taken  to  prevent  over- 
feeding ;  the  value  of  the  food  mixtures  in  calories  should  at  no  time  greatly 
exceed  the  nutritional  demands  of  the  infant.  It  is  also  wise  to  feed  all 
rachitic  infants  at  a  four-hour  interval;  more  frequent  feedings  are  gen- 
erally fraught  with  disastrous  results. 

In  the  second  year  of  life  soft-boiled  eggs  are  a  very  important  adjunct 
to  the  dietetic  treatment;  the  yolk  of  the  egg  furnishing  the  fat  and  the 
white  the  albumin.  Meat  juice  and  beef  peptonoids  may  also  be  of  value 
in  those  cases  where  the  idiosyncrasies  of  the  child  make  it  impossible  to 
put  it  upon  a  proper  milk  formula.  Butter  is  a  palatable  and  easily  di- 
gested fat  which  may  be  given  on  bread  or  in  a  cereal  with  milk.  Eaw  or 
partially  cooked,  scraped  beef  is  a  food  of  great  value  when  it  can  be  prop- 
erly cared  for  by  the  digestive  organs  of  the  child. 

Fresh  air  and  sunshine  are  curative  measures  of  the  greatest  importance. 
There  can  be  no  doubt  that  the  fresh  air  and  sunshine  of  the  country,  under 
suitable  climatic  conditions,  are  of  themselves  direct  curative  agents,  but 
their  greatest  importance  lies  in  the  fact  that  they  very  materially  increase 
the  digestive  capacity  of  the  infant  for  fat  and  proteins,  and  thereby  hasten 
the  time  when  it  can  be  placed  upon  a  proper  diet. 

Cod-liver  oil  is,  next  to  a  suitable  diet,  the  most  valuable  remedy  we 
have  in  the  treatment  of  rickets,  and  the  excellent  results  which  come  from 
its  use  seem  to  indicate  that  its  great  value  does  not  altogether  lie  in  the 
fact  that  it  is  an  easily  assimilated  fat.  The  administration  of  cod-liver 
oil,  however,  should  not  be  begun,  in  advanced  cases,  until  we  have  par- 
tially solved  the  food  problem  as  outlined  above ;  but  in  mild  cases  it  should 
be  begun  at  once  and  in  severe  cases  as  soon  as  the  physician  believes  that 
the  digestive  capacity  of  the  infant  will  permit  of  its  administration.  As 
a  rule,  cod-liver  oil  is  well  tolerated  by  rachitic  infants;  it  should  be  admin- 
istered over  a  long  period  of  time  in  connection  with  the  dietetic  treatment. 
The  form  in  which  cod-liver  oil  is  given  will  depend  upon  the  individual 


TREATMENT  245 

idiosyncrasies  of  the  infant;  it  should  be  discontinued  if  it  produces  lack 
of  appetite  or  gastrointestinal  disturbances;  it  is  perhaps  best  given  com- 
bined with  one  of  the  malt  extracts.  These  preparations  are  palatable  and, 
as  a  rule,  improve  the  digestive  capacity  of  the  infant.  In  individual  in- 
stances, however,  it  may  be  better  to  give  the  pure  oil  or  one  of  the  palat- 
able emulsions.  For  an  infant  six  months  old  the  dose  may  be  from  15  to 
20  minims  three  times  a  day,  and  for  an  infant  one  year  of  age  twice  this 
amount.  Phosphorus,  so  highly  recommended  by  Kassowitz  and  Jacobi,  is 
of  value  in  the  treatment  of  rickets;  the  dose  should  be  from  1/300  to 
1/250  of  a  grain.  It  may  be  given  in  the  form  of  Thompson's  solution  of 
phosphorus,  which  may  be  mixed  with  whatever  form  of  cod-liver  oil  prep- 
aration the  infant  is  taking.  Iron,  in  the  form  of  the  saccharated  carbonate 
or  some  other  easily  assimilated  preparation,  is  of  value  where  there  is 
marked  anemia  with  an  enlargement  of  the  spleen  and  lymph  nodes.  It  is, 
however,  advisable  to  get  the  infant  well  started  on  a  proper  food  formula, 
so  as  to  have  its  convalescence  well  under  way,  before  beginning  the  admin- 
istration of  iron. 

Salt  baths  have  been  recommended  and  are  perhaps  of  some  value  dur- 
ing the  acute  stage  of  the  disease. 

Oil  inunctions' bltq.  believed  to  be  of  value  throughout  the  whole  course 
of  the  disease.  Mild  general  massage,  followed  by  inunctions  of  anhydrous 
lanolin,  are  of  value  in  improving  nutritional  conditions.  This  treatment 
gives  mild  exercise  to  the  wasted  muscles  and  Joints  and  also  gives  the  in- 
fant a  certain  amount  of  fat,  which  is  taken  up  by  the  lymphatics  and 
blood  vessels  of  the  skin. 

Prevention  of  Deformities. — The  prevention  of  deformities  is  one  of 
the  most  important  duties  which  the  physician  has  to  observe  in  the  treat- 
ment of  acute  rickets.  During  the  active  stage  of  the  disease,  while  the 
bones  are  soft  and  flexible,  it  is  most  important  that  the  infant  should  be 
prevented  from  assuming  positions  that  will  result  in  bony  deformities.  It 
should  lie  upon  its  back  on  a  smooth  mattress,  and,  when  it  is  handled,  care 
should  be  taken  that  long-continued  pressure  in  any  one  position  may  not 
result  in  the  curvature  of  bones.  It  should  be  discouraged  from  walking, 
crawling,  and  sitting  alone  until  the  treatment  has  been  continued  long 
enough  to  overcome  the  softness  and  flexibility  of  the  bones.  It  may  in 
some  instances  be  necessary,  if  the  child  is  slow  in  its  recovery,  to  resort  to 
l)races  and  other  supports  to  prevent  curvatures  of  the  spine  and  of  the 
bones  of  the  leg. 

Treatment  of  Rachitic  Deformities. — There  is  a  tendency  on  the 
part  of  nature  to  gradually  overcome  the  deformities  which  result  from  the 
contraction  of  the  ribs,  the  curvature  of  the  spine,  and  the  distended  abdo- 
men. She  may  be  assisted  in  her  laudable  purpose  by  subjecting,  the  child 
to  systematic  gymnastic  exercise  under  the  guidance  of  a  competent  in- 
structor. The  surgical  treatment  of  old  rachitic  deformities,  especially  of 
the  long  bones,  is  of  great  value,  but  this  is  a  subject  which  belongs  to  the 
field  of  orthopedic  surgery. 


246  INFANTILE  SCUKVY 

CHAPTEE   XXX 

INFANTILE    SCUEVY 

(Scorhutiis) 

Definition.— Scurvy  is  a  chronic  nutritional  disorder  due  to  a  prolonged 
absence  or  diminution  of  certain  food  constituents  which  are  absolutely 
necessary  to  normal  metabolic  processes;  the  exact  nature  of  this  food  de- 
ficiency is  not  altogether  clear.  The  medical  world  inclines  to  believe  with 
Barlow,  Northrup,  Crandall,  and  others,  that  infantile  scurvy  is  -the  same 
disease  as  scorbutus  in  the  adult ;  the  clinical  picture  being  modified,  as  it 
is  in  so  many  other  diseases,  by  the  somewhat  different  chemical  and  bio- 
logical problems  found  in  the  immature  and  rapidly  developing  organism  of 
the  infant.  Eickets  and  scurvy  are  so  commonly  associated  in  the  infant 
that  for  many  years  there  was  great  confusion  in  their  differential  diagnosis, 
it  being  commonly  believed  that  scurvy  in  the  infant  was  a  manifestation 
of  rickets.  In  recent  years,  however,  the  well-recognized  hemorrhagic 
tendency  of  infantile  scurvy  and  its  general  resemblance  to  scorbutus  in 
the  adult  have  led  to  the  very  general  belief  that  it  is  an  independent  affec- 
tion commonly  associated  with,  but  not  otherwise  related  to,  rickets  either 
in  its  etiology,  pathology,  or  treatment. 

Etiologfy. — Infantile  scurvy  is  for  the  most  part  a  disease  of  the  first 
and  second  years  of  life ;  the  great  majority  of  cases  occur  between  the  sixth 
and  the  eighteenth  montli ;  it  rarely  begins  before  the  third  month  or  after 
the  second  year.  It  occurs  more  frequently  in  infants  of  the  middle  and 
upper  classes,  because  they  are  not  uncommonly  fed  on  a  food  which  at 
some  time  or  other  in  its  preparation  has  been  subjected  to  superheating; 
in  this  it  differs  markedly  from  rickets,  which  is  more  common  among  the 
poor  because  of  the  ill-balanced  food  formulas  upon  which  these  infants 
are  fed. 

Diet. — Some  dietetic  error  is  the  all-important  cause  of  the  develop- 
ment of  scurvy.  The  report  of  the  American  Pediatric  Society's  Collective 
Investigation  of  Infantile  Scurvy  in  1898  showed  that  of  379  cases  the 
food  upon  which  the  disease  developed  was  as  follows : 

Breast-milk in  12  cases,  alone  in  10 

Eaw  cow 's  milk in  5  cases,  alone  in     4 

Pasteurized  milk in  20  cases,  alone  in  16 

Condensed  milk   in  60  cases,  alone  in  32 

Sterilized  milk in  107  cases,  alone  in  68 

Proprietary  infant-foods in  214  cases. 

This  report  shows  that  scurvy  most  commonly  develops  on  the  propri- 
etary foods,  sterilized  milk,  condensed  milk  and  pasteurized  milk  and  that 
it  very  uncommonly  develops  on  raw  cow's  milk  and  breast  milk.  In  most 
of  the  cases  in  which  scurvy  has  developed  on  breast  milk,  the  milk  is  either 


SYMPTOMATOLOGY  247 

defective  in  composition,  as  shown  by  chemical  analysis,  or  exclusive  breast 
feeding  has  been  continued  for  too  long  a  time. 

In  studying  the  dietetic  causes  of  scurvy  one  is  led  to  the  conclusion 
that  the  fault  must  lie  chiefly  in  the  absence  of  some  fresh  principle  in  the 
food,  which  is  either  destroyed,  chemically  changed,  or  rendered  less  diges- 
tible or  assimilable  by  heat.  It  is  evident  that  heat  may  act  by  destroying 
active  biological  properties  of  the  food  which  are  necessary  in  infantile 
metabolism,  or  it  may  act  by  producing  changes  in  the  acids  and  salts  of 
fresh  foods ;  these  acids  and  salts  being  in  part  separated  from  their  protein 
combinations  by  heat  and  their  biological  and  chemical  value  thereby  im- 
paired in  the  body  metabolism.  Whether  or  not  this  be  the  explanation, 
the  fact  remains  that  food  that  has  been  biologically  killed  by  heat,  as  in 
the  sterilization  of  milk  or  in  the  preparation  of  proprietary  foods,  is  re- 
sponsible for  over  90  per  cent,  of  the  cases  of  infantile  scurvy.  The  char- 
acter of  the  food  formula,  which  is  all-important  in  the  etiology  of  rickets, 
has  little  to  do  with  the  production  of  scurvy,  and  the  fact  that  the  pro- 
prietary foods  which  are  such  a  prolific  cause  of  scurvy  in  infants  are  also 
ill-balanced  in  the  percentages  of  their  important  ingredients,  explains  why 
scurvy  and  rickets  are  so  commonly  associated  in  the  same  infant.  A  food 
that  contains  too  little  fat,  protein,  and  salts  may  produce  rickets,  while,  on 
the  other  hand,  as  a  result  of  the  changes  which  heat  has  produced  in  it,  it 
may  produce  scurvy. 

A  very  small  percentage  of  the  cases  occur  in  children  fed  on  breast 
milk  and  on  raw  cow's  milk.  That  these  unusual  cases  cannot  in  every  in- 
stance be  explained  by  a  chemical  analysis  of  the  milk  does  not  militate 
against  the  fact  that  food  that  has  been  changed  by  heat  is  the  all-important 
cause  of  this  disease.  When  scurvy  occurs  in  an  infant  fed  on  breast  milk 
or  raw  cow's  milk  the  rational  conclusion  is  that  this  particular  milk  has 
suffered  some  important  chemical  or  biological  change,  even  though  the 
science  of  chemistry  may  not  be  able  to  reveal  its  nature. 

Morbid  Anatomy. — The  characteristic  changes  are  produced  by  hemor- 
rhages which  may  be  very  widespread;  the  most  notable  are  the  subperios- 
teal hemorrhages  of  the  long  bones,  which  may  be  very  extensive  along  their 
shafts  and  at  their  epiphyseal  junction.  The  diaphyses  and  epiphyses  of 
these  bones  may  separate,  causing  marked  deformities.  Hemorrhages  may 
also  occur  in  the  medullary  canals  and  characteristic  changes  occuj-  in  the 
bone  marrow,  which  becomes  poor  in  cells  and  blood  vessels.  The  muscles, 
the  pleura,  the  pericardium  and  peritoneum  may  be  the  sites  of  small  hem- 
orrhages, and  the  gums  are  spongy  and  hemorrhagic.  In  a  large  percent- 
age of  the  cases  the  minute  changes  occurring  in  bones  are  similar  to  those 
seen  in  rickets,  but  these  changes  are  caused  by  the  rickets,  which  is  so  com- 
monly associated  with  scurvy,  and  do  not  belong  properly  to  the  pathology 
of  this  disease. 

Sjnnptomatology. — Tenderness  of  the  legs  and  sometimes  of  other  por- 
tions of  the  body  is  one  of  the  earliest  and  most  characteristic  symptoms; 
this  is  manifested  by  the  infant  crying  when  it  is  handled  and  by  its  re- 


248  INFANTILE   SCURVY 

maining  quiet  when  it  is  allowed  to  rest  in  its  bed.  The  importance  of  this 
sign  is  emphasized  by  the  fact  that  the  natural  instincts  of  the  infant  are 
here  reversed ;  if  an  infant,  contrary  to  all  the  instincts  of  its  nature,  cries 
and  frets  when  it  is  taken  up  and  fondled  by  its  mother  and  becomes  quiet 
again  when  it  is  replaced  in  bed,  this  can  only  be  explained  by  the  fact 
that  the  handling  causes  pain.  This  leads  to  the  suspicion  that  the  child 
has  been  injured,  and  an  investigation  on  the  part  of  the  mother  often 
confirms  her  in  this  belief,  since  she  finds  that  the  child,  even  when  lying 
in  its  bed,  will  cry  with  pain  when  some  particular  portion  of  the  body  is 
moved.  A  further  investigation  may  develop  the  fact  that  the  legs  are 
tender  to  the  touch  and  are  swollen  about  the  knees  and  ankles.  These 
swellings  are  commonly  fusiform  in  shape  and  are  due  to  the  subperiosteal 
hemorrhages,  which  may  extend  from  the  ankle  to  the  knee,  and,  being 
more  marked  near  these  joints,  may  in  severe  cases  cause  a  separation  of 
the  epiphyses  and  diaphyses.  The  soreness  and  tenderness  produced  by 
these  swellings  cause  the  infant  to  hold  its  legs  as  motionless  as  possible, 
thus  producing  the  pseudo-paralysis  of  scurvy.  This  false  paralysis  results 
from  the  tense  condition  of  the  muscles  which  holds  the  legs  immovable  and 
is  perhaps  the  result  of  reflex  rather  than  of  voluntary  action  on  the  part 
of  the  infant ;  this  condition  of  immobility  is  even  greater  when  the  spinal 
column  is  involved.  The  severity  of  these  symptoms  grows  apace  as  the 
disease  advances,  until  the  infant  is  in  a  pitifully  helpless  condition,  scream- 
ing with  pain  at  the  slightest  movement  or  crying  out  with  fear  when  it  is 
approached  by  the  physician.  In  these  severe  cases  the  sternum  may  be 
separated  from  the  ribs  and  sunken  backward,  producing  a  characteristic 
deformity. 

Hemorrhage  into  the  gums  is  an  early  and  characteristic  symptom.  The 
gums  may  be  purple  and  swollen  and  when  teeth  are  present  hemorrhages 
are  more  frequent;  they  may  bleed  when  touched  and  there  may  be  evi- 
dences of  spontaneous  petechial  hemorrhages  in  the  vault  of  the  pharynx 
and  other  parts  of  the  mouth.  Hemorrhages  may  occur  from  other  mucous 
membranes,  as  is  evidenced  by  the  fact  that  blood  is  occasionally  found  in 
the  feces  and  in  the  urine.  They  may  also  occur  in  the  subcutaneous  tis- 
sues about  the  joints  and  other  parts  of  the  body,  as  well  as  in  the  con- 
junctiva and  orbit.    In  this  latter  position  they  may  produce  exophthalmos. 

Enterocolitis  may  be  present  in  severe  cases.  The  child  is  irritable, 
anemic,  and  suifers  from  general  malnutrition;  in  advanced  cases  the 
anemia  and  malnutrition  are  very  marked.  The  blood  findings  may  be 
those  of  an  ordinary  secondary  anemia  or  they  may  be  of  the  chlorotic  type. 
The  urine  not  uncommonly  contains  albumin  and  casts.  In  advanced  cases 
fever  is  usually  present,  but  it  is  inconstant  and  irregular  in  type  and  is 
perhaps  due  to  intestinal  and  other  complications. 

Diagnosis. — The  crying  of  the  infant  on  being  taken  up,  the  swelling 
and  tenderness  of  the  joints,  the  hemorrhagic  condition  of  the  gums,  and 
the  history  of  the  child  having  been  fed  upon  a  food  which  may  develop 
scurvy,  are  commonly  sufficient  to  make  the  diagnosis.    In  making  a  differ- 


TREATMENT  249 

ential  diagnosis,  however,  the  physician  should  remember  that  rheumatism 
presenting  the  above  symptoms  very  rarely,  in  fact  almost  never,  occurs  in 
infancy,  but  if  rheumatism,  osteomyelitis,  or  periostitis  be  suspected  in  an 
infant  presenting  the  above  symptoms,  the  differential  diagnosis  of  these 
diseases  from  scurvy  can  be  readily  made  by  the  dietetic  treatment  subse- 
quently outlined. 

Prognosis. — The  prognosis,  when  the  disease  is  recognized  early,  is  good. 
In  neglected  cases  which  have  come  into  the  hands  of  the  physician  too  late 
to  respond  to  treatment,  death  may  occur  from  malnutrition,  enterocolitis, 
pneumonia,  or  hemorrhage. 

Treatment. — Prophylactic  treatment  is  of  the  very  greatest  im- 
portance. In  many  instances  the  physician,  especially  in  dispensary  prac- 
tice, is  forced  to  superintend  the  feeding  of  an  infant  during  the  hot  months 
of  summer,  where  the  conditions  are  such  that  he  must  use  foods,  the  long 
continuance  of  which  may  produce  scurvy.  When  these  sterilized  and 
cooked  foods  are  given  for  any  length  of  time  it  is  certainly  the  part  of  wis- 
dom to  direct  that  from  time  to  time  these  infants  be  given  a  certain 
amount  of  orange  juice.  This  will  effectually  prevent  the  development  of 
scurvy. 

The  CURATIVE  TREATMENT  of  scurvy  is  almost  as  simple  as  the  prophy- 
lactic treatment  and  consists  in  giving  the  infant  some  kind  of  fresh  or 
uncooked  food,  either  with  or  as  a  substitute  for  the  food  which  it  has  been 
taking.  Fresh  fruit  juice  is  a  specific  for  scurvy.  Orange  juice  is  gen- 
erally used,  because  it  can  be  obtained  at  any  season  of  the  year,  and  because 
it  more  commonly  agrees  with  the  infantile  digestive  organs  than  other 
fruit  juices.  One  may  begin  by  giving  a  teaspoonful  of  orange  juice, 
slightly  sweetened,  if  necessary,  five  or  six  times  a  day.  An  existing  gas- 
troenteritis does  not  contraindicate  the  use  of  orange  or  other  fruit  juices. 
Under  this  therapeutic  measure  the  pain  and  tenderness  about  the  joints 
may  disappear  in  four  or  five  days,  and  a  cure  may  confidently  be  expected 
within  two  or  three  weeks.  As  the  child  improves  and  the  gastrointestinal 
condition  becomes  normal,  the  amount  of  orange  juice  may  be  increased  to 
six  tablespoonfuls  in  the  twenty-four  hours.  It  may  be  advisable  to  give 
fresh  beef  juice  in  connection  with  the  fruit  juices  in  the  beginning  of  the 
treatment.  Later,  potatoes  that  have  been  steamed  and  mashed  and  the 
juice  of  fresh  vegetables  may  be  given  with  advantage.  The  mistake  is 
very  commonly  made  in  advanced  scurvy  of  immediately  attempting  to 
substitute  a  diet  of  fresh  cow's  milk  for  the  proprietary  food  upon  which 
the  infant  has  been  living.  There  can  be  no  question  as  to  the  advisability 
of  such  a  procedure  provided  the  infant's  digestive  capacity  is  equal  to 
the  change.  But  in  most  instances  this  change  has  to  be  brought  about 
very  gradually  and  should  not  be  begun  until  the  infant  has  commenced  to 
respond  to  the  specific  treatment  above  noted;  the  change  to  fresh  cow's 
milk  is  then  brought  about  as  rapidly  as  the  infant's  digestive  capacity  will 
permit.  The  raw  cow's  milk  itself,  like  the  fruit  juices,  has  a  curative « 
influence  and  is  also  necessary  to  remove  the  malnutrition  which  has  re- 


250  DIABETES    MELLITUS 

suited  from  the  scurvy  and  concurrent  rickets.  As  the  infant  improves, 
the  orange  juice  and  heef  juice  are  continued  and  cod-liver  oil  and  iron  are 
given.  The  cod-liver  oil  is  especially  valuable  in  those  cases  where  rickets 
complicates  the  scurvy. 


CHAPTEE   XXXI 

DIABETES    MELLITUS 

In  the  infant  and  young  child  diabetes,  as  a  rule,  runs  a  rapidly  fatal 
course;  the  younger  the  child  the  more  rapid  and  the  more  fatal  is  this 
disease.  It  rarely  occurs  in  infancy,  but  is  occasionally  seen  in  the  young 
child. 

The  etiology  and  pathology  of  diabetes  in  the  child  are  the  same  as 
in  the  adult. 

Symptomatology. — Among  the  earliest  symptoms  noted  are  thirst,  fre- 
quent urination,  loss  of  weight  and  strength,  lassitude,  and  anemia.  An 
increased  thirst  and  appetite  causes  the  child  to  drink  large  quantities  of 
water  and  to  eat  more  than  the  normal  amount  of  food.  An  excessive 
quantity  of  urine  is  passed,  having  a  high  specific  gravity,  containing  large 
quantities  of  glucose,  and  later  acetone,  diacetic,  and  oxybutyric  acids  are 
found.  As  the  disease  progresses  the  child  loses  in  weight  and  strength,  its 
appetite  begins  to  fail,  its  insatiable  thirst  continues,  the  intake  of  water 
becomes  greater  and  greater,  the  quantity  of  urine  is  proportionately  in- 
creased, it  becomes  irritable  and  restless,  the  skin  and  mucous  membranes 
are  dry,  furunculosis  may  develop,  an  acetone  odor  may  be  detected  on  the 
breath,  and  finally  a  somnolence  followed  by  diabetic  coma  may  terminate 
in  death. 

Treatment. — The  treatment  of  diabetes  in  the  child  is  the  same  as  in 
the  adult.  The  quantity  as  well  as  the  quality  of  the  food  is  important. 
The  child  should  be  given  only  a  sufficient  number  of  calories  to  supply  its 
nutritional  needs,  and  the  diet  should  be  made  up  of  the  ordinary  diabetic 
foods  prescribed  for  adults.  In  beginning  the  treatment  it  is  even  more 
important  than  it  is  in  the  adult  that  the  patient  should  be  placed  upon  a 
strictly  diabetic  diet  and  that  the  quantity  of  water  which  the  child  takes  in 
twenty-four  hours  should  be  limited  as  much  as  possible.  If  the  urine, 
upon  a  strict  diabetic  diet,  can  be  made  sugar-free  there  is  a  chance  that 
under  careful  dietetic  management  life  may  be  prolonged  for  many  years, 
and  that  a  cure  may  be  effected  in  a  small  percentage  of  cases.  It  is  neces- 
sary, however,  after  the  urine  has  remained  sugar-free  for  a  few  weeks,  that 
certain  carbohydrates  should  be  added  for  the  purpose  of  developing  a  toler- 
ance for  this  class  of  foods.  The  carbohydrates  which  are  thus  to  be  added 
in  small  quantities  to  the  diet  should  be  first  oatmeal,  then  potatoes,  and 
later  small  quantities  of  wheat  bread.  The  dietetic  management,  however, 
of  these  cases  cannot  be  discussed  in  detail  here,  since  this  chapter  is  a  long 


EECURRENT  VOMITING  361 

one  and  may  be  found  in  any  modern  textbook  on  medicine.  The  point 
to  be  emphasized  is  that  unless  the  child  can  be  got  into  a  condition  in 
which  it  can  metabolize  certain  carbohydrates  such  as  those  mentioned, 
without  causing  an  increase  of  sugar  in  the  urine,  the  case  is  a  hopeless  one. 


CHAPTER    XXXII 
RECUEKENT    VOMITING,    RECURRENT    CORYZA    AND    MIGRAINE 

RECURRENT  VOMITING 

Synonyms. — Cyclic  vomiting,  lithemic  vomiting,  migrainous  gastric 
neurosis,  periodical  vomiting,  bilious  vomiting,  vomiting  with  acetonemia. 

Definition. — Recurrent  vomiting,  which  is  one  of  the  most  common  dis- 
eases of  early  childhood,  is  an  autointoxication  produced  by  systemic  and 
probably  intestinal  toxins.  It  is  characterized  by  recurring  attacks  of 
nausea,  persistent  vomiting,  prostration,  and  the  appearance  of  acetone 
bodies  in  the  urine. 

Etiology. — Liver  Incompetency, — The  failure  on  the  part  of  the  liver 
to  neutralize  or  destroy  systemic  and  intestinal  toxins  is,  I  believe,  the 
most  important  cause  of  this  disease.  This  hypothesis  assumes  that  the 
liver,  from  various  causes,  the  chief  of  which  is  overwork,  more  or  less  sud- 
denly develops  a  functional  incompetency  which  renders  it  incapable  of 
converting  ammonia  and  the  purin  bodies  into  urea  and  destroys  its  so- 
called  filtering  function,  which  normally  renders  innocuous  the  fermenta- 
tion products  which  pass  through  it  from  the  intestinal  canal.  As  a  result 
of  this  liver  inactivity  both  systemic  and  intestinal  toxins  escape  into  the 
general  circulation  and  produce  an  autointoxication  which  is  named  from 
its  most  prominent  symptom  "Recurrent  Vomiting."  After  a  few  hours  or 
days,  as  the  case  may  be,  the  liver  resumes  its  function  and  the  acute  attack 
of  autointoxication  is  ended.  In  those  very  rare  cases  where  this  condition 
terminates  fatally  there  is  a  well-marked  fatty  degeneration  of  liver  cells. 
Howland's  and  Richards'  investigations  indicate  that  the  chief  metabolic 
disturbance  underlying  recurrent  vomiting  is  deficient  oxidation  and  also 
that  the  products  of  intestinal  fermentation  (indol,  etc.)  are  more  or  less 
directly  responsible  for  the  symptoms.  There  are  many  factors,  predispos- 
ing and  exciting,  which  in  individual  cases  help  to  produce  the  liver  incom- 
petency which  causes  this  widely  varying  sjrmptom  group.  This  variability 
may  be  explained  by  the  fact  that  it  is  not  always  produced  by  the  same 
autotoxins.  In  one  group  of  cases  the  intestinal  toxins  may  dominate, 
and  in  another  the  systemic;  in  still  another  the  autointoxication  may  be 
almost  or  quite  overshadowed  by  nervous  symptoms  produced  by  powerful 
exciting  causes.  In  these  cases  the  symptoms  of  hysteria  and  other  neuroses 
may  be  commingled  with  those  of  autointoxication. 

Exciting  Causes. — Overeating  is  perhaps  the  most  common  of  all  ex- 


252     RECUKRENT    VOMITING,  CORYZA,    AND    MIGRAINE 

citing  factors.  Individual  idiosyncrasies  with  reference  to  the  metabolism 
of  certain  food  stuffs  are  most  important;  defective  carbohydrate  metabol- 
ism is  very  commonly  present  in  infants  and  children,  to  such  a  degree  that 
an  excess  or  even  ordinary  quantities  of  sugars  and  sometimes  of  starches  is 
quickly  followed  by  attacks  of  autointoxication;  an  inability  to  metabolize 
excessive  quantities  or  even  normal  quantities  of  fat  is  also  very  common; 
defects  in  protein  metabolism  are  less  rarely  seen.  In  some  instances,  fol- 
lowing a  "food  injury"  to  the  metabolism  from  an  excessive  intake  of  either 
fats  or  sugars,  the  child  for  months  or  years  may  not  be  able  to  take  even 
comparatively  small  quantities  of  one  or  other  of  these  foods  without 
producing  an  attack  of  recurrent  vomiting.  In  time,  however,  under  care- 
ful feeding  it  may  gradually  recover  its  normal  powers  of  metabolizing 
these  foods.  Food  idiosyncrasies  are  not  confined  to  fats  and  sugars ;  acid 
fruits,  certain  vegetables,  eggs,  or  milk  may  in  individual  cases  be  followed 
by  attacks.  The  trouble  in  such  cases  is  not  solely  a  question  of  digestion, 
but  also  one  of  metabolism.  Food  idiosyncrasies,  therefore,  must  be  looked 
for  in  every  case. 

Among  other  exciting  causes, may  be  mentioned  mental  and  physical 
fatigue,  mental  excitement,  nervous  strain,  fright,  anger,  acute  infections, 
general  anesthesia,  especially  by  ether,  and  severe  reflex  irritation  originat- 
ing in  the  eye,  nasopharynx,  or  genitourinary  organs. 

The  acidosis  which  occurs  in  recurrent  vomiting  is,  in  most  cases,  a 
very  important  part  of  the  pathological  process  and  when  well  pronounced 
no  doubt  contributes  to  the  production  of  the  clinical  syndrome  of  this 
disease.  It  may  occur  early  or  it  may  appear  late,  and  in  a  small  minority 
of  cases  it  is  not  present  at  all.  It  is  not  to  be  considered  as  an  etiological 
factor,  but  rather  as  an  important  symptom  of  this  condition.  The  path- 
ology of  acidosis  is  elsewhere  discussed. 

Predisposing  Causes. — Heredity  is  a  most  important  predisposing  fac- 
tor; a  family  history  of  migraine,  gout,  or  neurotic  disease  is  present  in 
most  cases.  Constipation  is  nearly  always  present.  Recurrent  vomiting 
occurs  more  frequently  among  children  of  the  upper  classes.  Mental  over- 
work and  nerve  excitement,  combined  with  indoor  life  and  confinement  in 
ill-ventilated  rooms,  are  important  factors.  The  great  majority  of  cases 
occur  during  infancy  and  childhood.  I  have  seen  the  first  symptoms  ap- 
pear as  early  as  the  third  month,  but  it  is  most  commonly  seen  between  the 
third  and  tenth  year;  after  this  period  the  tendency  is  to  spontaneous  re- 
covery, or  to  a  change  in  form  of  the  autotoxic  attacks  in  which  vomiting 
plays  a  secondary  role.  They  may  gradually  be  transformed  in  the  older 
child  and  adult  into  true  migraine.  They  are  slightly  more  common  in 
girls  than  in  boys  and  are  seen  more  frequently  in  winter  than  in  summer. 

Symptomatology. — General  Symptoms. — The  following  description 
presents  the  ordinary  type  of  this  disease.  There  is  usually  a  prodromal 
period  lasting  from  a  few  hours  to  a  few  days.  This  may  be  characterized 
by  sallowness  of  complexion,  dark  rings  under  the  eyes,  general  malaise, 
constipation,  coated  tongue,  disagreeable  odor  to  the  breath,  loss  of  appe- 


RECUREENT   VOMITING  253 

ate,  gastric  discomfort,  anorexia,  nausea,  general  nervous  irritability, 
sleeplessness,  flushing  of  the  cheeks,  and  possibly  coryza,  dyspnea,  and 
sighing  respirations.  The  stools  may  be  white  or  putty-like  in  color  with 
a  disagreeable  odor.  Not  all  of  these  prodromes  are  present  in  any  one 
case,  but  in  an  individual  case  the  same  prodromal  symptoms  commonly 
precede  the  recurring  attacks.  Occasionally,  without  warning,  the  attack 
may  be  ushered  in  with  vomiting,  quickly  followed  by  fever.  In  some  of 
my  cases  the  attacks  were  always  preceded  by  a  vasomotor  coryza. 

Vomiting. — This  is  the  most  constant  and  most  characteristic  symp- 
tom. In  the  beginning  it  may  not  be  severe,  but  in  a  few  hours  it  may 
become  very  violent  and  associated  with  retching,  the  vomitus  containing 
hydrochloric  acid,  mucus,  bile  and  rarely  blood;  in  the  interval  between 
the  attacks  there  may  lie  nausea.  The  vomiting  may  continue  for  a  few 
hours,  or  it  may  last  eight  or  nine  days;  when  it  continues  for  any  length 
of  time  it  produces  great  emaciation,  is  associated  with  great  prostration 
and  is  accompanied  by  insatiable  thirst.  When  the  vomiting  subsides 
the  gastrointestinal  canal  quickly  resumes  its  functions;  food  is  taken 
without  the  slightest  discomfort,  convalescence  is  rapid,  and,  within  from 
four  to  nine  days,  the  patient  has  fully  recovered.  Subsequent  attacks 
occur  at  irregular  intervals,  and  it  is  this  recurrence  which  leads  to  their 
differentiation  from  acute  gastritis.  When  second  or  third  attacks  of 
vomiting,  in  which  the  same  symptom  group  is  reproduced,  occur  in  spite 
of  careful  feeding  and  without  apparent  cause,  the  physician  must  suspect 
their  autotoxic  character  and  make  the  necessary  examinations  of  the  urine 
and  stomach  contents  which  confirm  the  diagnosis.  While  it  is  the  rule 
that  patients  suffering  from  recurrent  vomiting  have  little  or  no  gastric 
or  intestinal  disturbance  in  the  interval,  yet  this  is  a  rule  which  has 
many  exceptions,  especially  in  children  under  four  years  of  age.  In  the 
very  young  child  these  autotoxic  attacks  may  manifest  themselves  by  a 
difficulty  in  digesting  cow's  milk,  and  gastric  indigestion  associated  with 
vomiting  and  mild  intestinal  fermentations  may  intervene  between  the 
more  pronounced  attacks  of  recurrent  vomiting. 

Pain  is  usually  absent;  this  is  especially  true  of  recurrent  vomiting 
as  it  occurs  in  the  child.  In  those  cases  where  the  autotoxic  attacks  are 
continued  into  adult  life  severe  pain  in  the  head  or  stomach  may  be  asso- 
ciated with  the  vomiting. 

Constipation,  which  commonly  precedes  the  attack,  becomes  more  ob- 
stinate as  the  attack  goes  on,  and  it  is  one  of  the  most  difficult  symptoms 
to  relieve  because  the  irritable  condition  of  the  stomach  will  not  tolerate 
cathartic  medication.  When  the  constipation  is  relieved  by  cathartics  the 
discharges  are  putrid.     Diarrhea  occurs  in  rare  instances. 

In  severe  cases  the  emaciation  and  prostration  are  rapid  and  extreme; 
the  abdomen  is  boat-like  or  flattened,  the  eyes  are  sunken  and  the  face  has 
an  anxious  expression. 

Fever  from  101°  to  105°  F.  is  present  in  nearly  every  case;  the  younger 
the  child  the  more  marked  the  febrile  reaction.    In  the  older  child  the  tem- 


254     EECUERENT    VOMITING,  CORYZA,    AND    MIGRAINE 

perature  may  not  rise  above  normal.  After  the  second  or  third  day  the  tem- 
perature subsides  and  may  become  subnormal.  The  pulse  is  rapid  and  usu- 
ally irregular.  The  breathing  may  be  but  slightly  disturbed,  or  it  may  be 
rapid  and  panting;  in  some  cases  there  is  dyspnea  with  wheezy  respira- 
tory sounds.  The  peculiarly  sweet  and  rather  offensive  acetone  odor 
of  the  breatli  is  a  striking  symptom ;  as  a  rule  it  occurs  early,  and  in  a  few 
instances  is  never  present.  When  once  observed,  it  is  easily  recognized 
and  may  be  so  penetrating  that  it  is  noticed  on  entering  the  room.  As 
the  disease  progresses  the  tongue,  pharynx  and  lips  become  dry  and  irri- 
tated. Toward  the  close  of  a  severe  attack  there  is  a  tendency  to  som- 
nolence, and  a  prolonged  sleep  is  frequently  followed  by  the  first  indica- 
tions of  improvement. 

Children  who  suffer  from  recurrent  vomiting  are  usually  precocious 
and  neurotic.  They  present  varying  degrees  of  general  nervous  excitabil- 
ity and  restlessness,  even  in  the  interval  between  the  attacks.  In  very 
nervous  children,  as  Snow  has  noted,  convulsions  may  occur. 

Urixe. — The  acetone  bodies  are  the  most  characteristic  findings  in 
the  urine.  In  the  milder  cases  acetone  alone  may  be  found,  in  those  of 
moderate  severity  both  acetone  and  diacetic  acid,  and  in  more  severe  cases 
oxybutyric  acid  is  also  present.  The  urine  is  scanty,  concentrated  and 
hyperacid  and  in  severe  cases  albumin  and  hyalin  casts  are  present.  In- 
dican,  indolacetic  acid,  uric  acid,  and  the  xanthin  bodies  are  markedly 
increased  during  the  attack.  Rowland  and  Richards  report  an  increase  in 
the  unoxidized  sulphur  and  a  diminution  in  sulphuric  acid. 

The  Blood. — A  leukocytosis  of  16,000  to  20,000  commonly  occurs, 
with  a  relative  increase  in  the  small  lymphocytes. 

Diagnosis. — The  periodical  return  of  the  symptom  group  is  a  most 
important  diagnostic  indication.  The  presence  of  free  hydrochloric  acid 
in  the  vomited  matter  may  materially  assist  in  differentiating  this  condi- 
tion from  acute  gastritis,  and  the  urine  findings  above  noted,  with  the 
absence  of  pain  and  abdominal  tenderness,  should  differentiate  it  from 
appendicitis  and  intestinal  obstruction. 

Prognosis. — It  should  be  remembered  that  this  is  one  of  the  most  com- 
mon disorders  of  childhood  and  that  in  most  instances  it  will  be  overlooked 
if  systematic  examinations  of  the  urine  for  acetone  and  diacetic  acid  are 
not  insisted  upon.  The  prognosis,  as  far  as  recover}'  from  the  attack  is  con- 
cerned, is  good;  death,  however,  may  occur  from  exhaustion  or  from  a 
terminal  nephritis;  only  a  few  fatal  cases  have  been  reported.  The  prog- 
nosis as  to  the  prevention  of  these  attacks  is  also  good.  Under  proper 
medical  supervision  the  attacks  cease,  the  improvement  in  the  child's 
general  health  continues,  and  as  it  grows  older  its  nervous  system  becomes 
more  stable  and  a  tendency  to  these  recurring  attacks  is  thus  outgrown. 
Untreated  cases  may  later  be  transformed  into  migraine  or,  rarely,  into 
epilepsy. 

Clinical  Types. — It  should  be  understood  that  there  are  many  variations 
in  the  clinical  syndromes  grouped  under  the  general  heading  Recurrent 


RECURRENT   VOMITIXG  255 

Vomiting.  The  attack  may  not  proceed  beyond  the  prodromal  symptoms; 
in  many  cases  tliere  may  l)e  little  or  no  vomiting,  and  the  characteristic 
syndrome  may  be  marked  by  a  periodic  return  of  fever  lasting  one  or  two 
days,  associated  with  a  coated  tongue,  bad  breath,  lack  of  appetite,  nausea 
and  constipation.  In  other  instances,  especially  in  older  children,  the 
prodromal  symptoms  of  recurrent  vomiting  may  occur  associated  with 
nausea,  headache  and  narcotism,  and  in  still  another  group  the  same  pro- 
dromal symptoms  may  be  associated  with  a  recurrent  coryza  or  a  recur- 
rent asthma,  which  may  or  may  not  be  accompanied  by  nausea  and  occa- 
sional vomiting.  If  one  remembers  that  the  symptom  group  above  out- 
lined may  present  itself  in  all  grades  of  severity,  but  that  in  the  same 
individual  these  attacks  closely  resemble  one  another,  there  will  be  little 
difficulty  in  making  a  diagnosis. 

There  is  another  syndrome  associated  with  a  marked  acidosis  described 
by  Thomas  D.  Parke,  which  my  experience  leads  me  to  believe  is  a  dis- 
tinct clinical  entity  due  to  some  severe  toxemia.  It  occurs  most  commonly 
in  children  under  three  or  four  years  of  age.  The  symptoms  in  the 
beginning  are  those  of  acute  gastrointestinal  infection.  There  is  diarrhea 
and  nausea  and  commonly  an  acetone  odor  to  the  breath.  The  stools 
usually  contain  mucus  and  blood,  are  passed  with  more  or  less  straining 
and  are  frequently  preceded  by  intestinal  colic.  Labored  and  rapid  breath- 
ing is  a  prominent  symptom.  The  liver  is  enlarged.  There  may  be  a 
slight  fever,  but  as  the  disease  progresses  the  temperature  becomes  sub- 
normal. There  is  marked  prostration  and  the  disease  commonly  comes  to 
a  fatal  termination  with  an  increasing  gastrointestinal  irritation  and  a 
marked  increase  of  the  acetone  bodies  in  the  urine.  This  symptom  group 
is  much  more  severe,  much  more  dangerous  and  differs  materially  from 
the  ordinary  syndrome  of  recurrent  vomiting.  The  fatal  cases  terminate 
within  three  or  four  days  after  the  onset  of  severe  symptoms.  The  post- 
mortem findings  show  an  enlarged  liver,  which  has  undergone  fatty  de- 
generation, and  there  may  be  fatty  degeneration  of  other  organs.  Apart 
from  this  the  pathological  findings  are  not  definite. 

Treatment. —Treatment  of  the  Attack. — If  seen  in  the  prodromal 
stage,  one-fourth  of  a  grain  of  calomel  and  five  grains  of  bicarbonate  of 
soda  should  be  given  every  half  hour  until  two  grains  of  calomel  are 
taken,  and  two  or  three  hours  later  a  saline  laxative  should  be  given.  This 
should  be  followed  by  five  or  ten  grains  of  bicarbonate  of  soda  every  two 
or  three  hours  over  a  period  of  several  days,  administered  in  carbonated 
water,  plain  water  or  peppermint  water.  No  food  whatever  should  be 
allowed  for  at  least  twenty-four  or  thirty-six  hours,  or  until  the  nausea  and 
vomiting  have  been  controlled.  After  the  attack  is  well  on  the  nausea 
and  vomiting  may  preclude  not  only  all  food,  but  all  stomach  medication. 
The  calomel  and  bicarbonate  of  soda,  however,  may  be  tried  at  any  stage 
of  the  attack,  and  if  the  nausea  and  vomiting  are  not  aggravated  they 
may  be  continued.  At  intervals  throughout  the  attack  water  may  be  allowed 
in  small  quantities,  even  though  the  stomach  rejects  it;  when  the  patient 
18 


256     RECURRENT    VOMITING,  CORYZA,    AND    MIGRAINE 

is  able  to  retain  water,  then  small  quantities  of  thin  beef  broth  may  be 
given.  If  water  is  not  retained  by  the  stomach  it  is  advisable  to  give,  at 
intervals  of  six  or  eight  hours,  high  rectal  enemata  of  6  or  8  ounces  of 
physiological  salt  solution,  or  of  a  1  per  cent,  bicarbonate  of  soda  solution. 
Edsal's  suggestion  that  large  doses  of  bicarbonate  of  soda  be  given  by  the 
mouth  is  a  good  one  in  those  cases  where  the  soda  is  retained,  but  the  great 
discomfort  and  exhaustion  which  follow  attacks  of  vomiting  teach  us  that 
it  is  wise,  when  the  stomach  is  very  irritable,  to  let  it  have  a  period  of 
prolonged  rest  and  then  attempt  to  give  bicarbonate  of  soda  by  the  mouth 
in  8-  or  10-grain  doses  every  two  or  three  hours.  In  the  most  aggravated 
cases,  where  prostration  is  extreme  and  vomiting  has  continued  over  a  num- 
ber of  days,  8  to  16  ounces  of  sterile  physiological  salt  solution  combined 
with  five  or  ten  grains  of  bicarbonate  of  soda  to  the  ounce  may  be  injected 
into  the  subcutaneous  tissues.  In  this  same  type  of  case  the  hypodermic 
use  of  morphin  frequently  controls  the  vomiting,  and  may,  like  hypo- 
dermoclysis,  be  a  life-saving  measure.  Small  doses  of  from  1/20  to  1/60 
of  a  grain  of  morphin,  depending  upon  the  age  of  the  child,  are  usually 
sufficient  to  control  the  irritability  of  the  stomach  long  enough  to  allow 
the  bicarbonate  of  soda  solution  given  by  the  mouth  to  be  al)sorbed. 
When  necessary  the  morphin  and  the  hypodermoclysis  may  be  repeated 
at  intervals  of  eight  to  twelve  hours. 

Interval  Treatment. — WTien  the  child  is  convalescent  causes  of 
reflex  irritation  to  the  nervous  system  should  be  carefully  sought  for  and 
removed.  Constipation,  which  is  usuall}-  present,  must  be  relieved;  this 
may  be  done  by  palatable  solutions  of  sulphate  and  phosphate  of  soda. 
These  saline  laxatives  are  advisable  in  beginning  the  treatment;  later  cas- 
cara  sagrada,  rhubarb  and  other  cathartics  may  be  used;  enemata  are  not 
to  be  relied  upon.  Abdominal  massage  may  relieve  the  constipation. 
General  massage  is  one  of  our  most  valued  remedies  in  overcoming  the 
constitutional  conditions  which  predispose  to  recurrent  vomiting;  it  is 
especially  indicated  in  patients  of  feeble  constitution  who  are  not  strong 
enough  to  enjoy  the  benefits  of  outdoor  life  and  active  exercise. 

In  the  early  interval  treatment  of  this  condition  the  wintergreen  sali- 
cylate of  soda  and  the  benzoate  or  bicarbonate  of  soda  put  up  in  palatable 
solution  are  our  most  valued  remedies;  two  grains  of  the  salicylate  and 
five  grains  of  the  bicarbonate  may  be  given  to  a  child  six  years  of  age 
over  a  period  of  months.  After  three  or  four  months  these  remedies  may 
be  given  once  or  twice  a  day  for  a  year  or  more,  as  the  indications  may 
direct.  If  during  this  time  the  prodromal  symptoms  of  an  attack  make 
their  appearance,  the  calomel  and  bicarbonate  of  soda  are  to  be  given 
as  previously  directed,  and  then  the  salicylate  and  bicarbonate  of  soda 
are  to  be  resumed.  From  a  very  large  experience  I  have  the  greatest  faith 
in  the  efficacy  of  the  interval-medical  treatment  as  here  outlined.  It  may 
be  necessary  occasionally  to  interrupt  the  alkaline  treatment  and  substitute 
such  tonics  as  malt  and  arsenic;  after  a  time,  however,  it  is  necessary  to 
return  to  the  alkaline  treatment. 


KECUREENT    VOMITING  257 

In  the  treatment  of  recurrent  vomiting  in  older  children  I  use  the 
formula  which  I  originated  many  years  ago  for  the  treatment  of  migraine. 
It  is  as  follows : 

Sodii  sulphatis  (dry) 30  grains 

Sodii  salieylatis    (from  wintergreen) 10  grains 

Magnesii  sulphatis 50  grains 

Lithii  benzoatis   5  grains 

Tincturae  nucis  vomicae 3  drops 

Aquse  destil.  to  make 4  ounces 

This  prescription  is  put  up  in  siphons  and  charged  with  carbonic  acid, 
and  the  child  is  directed  to  take,  half  an  hour  before  breakfast,  a  suffi- 
cient quantity  to  produce  at  least  one  bowel  movement  during  the  morn- 
ing. This  prescription  is  a  remedy  of  great  value  in  the  preventive 
treatment,  not  only  of  recurrent  vomiting,  but  also  of  migraine;  it  may  in 
fact  replace  all  other  medication. 

Dietetic  Treatment. — This  is  of  very  great  importance.  In  begin- 
ning the  treatment  all  sweets,  fats,  raw  fruits,  strawberries,  rhubarb, 
tomatoes,  salads,  tea,  coffee,  beef-juice,  beef-tea,  pastry,  gravies,  cream, 
cod-liver  oil  and  alcohol  are  to  be  avoided,  and  the  child  should  not  be 
allowed  to  eat  large  quantities  of  meat.  The  following  foods  may  be  recom- 
mended :  skim-milk,  vegetable  soups,  cereals,  well-cooked  vegetables,  cooked 
fruits,  bread,  eggs,  fish,  chicken,  mutton  and  beef.  It  is  most  important 
that  children  suffering  from  recurrent  vomiting  should  be  guarded  against 
an  excess  of  food  of  any  kind  and  that  sweets  of  all  kinds  should  be  care- 
fully excluded.  It  will  be  found  that  in  certain  instances  the  sweets  are 
the  prime  cause  of  the  trouble,  while  again  in  other  cases  the  attacks  can- 
not be  controlled  until  the  fats  are  eliminated  from  the  diet.  The  diet 
of  the  child  should  be  carefully  balanced;  if,  for  example,  he  happens  to 
be  an  excessive  meat  eater,  the  meats  should  be  somewhat  restricted  and 
a  proper  proportion  of  vegetables,  cooked  fruits,  or  cereals  given,  and  the 
child  should  also  be  made  to  cultivate  the  habit  of  drinking  as  much  water 
as  possible. 

Hygienic  and  Climatic  Treatment. — As  suboxidation  is  one  of  the 
essential  underlying  pathological  processes  of  this  disease,  it  is  necessary 
that  the  child  should  have  as  much  fresh  air  and  outdoor  exercise  as  pos- 
sible. Most  of  these  children  prefer  an  indoor  life  and  intellectual  pur- 
suits, so  that  it  becomes  necessary  for  the  physician  to  give  special  direc- 
tions with  reference  to  open  air  sleeping  apartments  and  the  number  of 
hours  of  outdoor  play  which  the  strength  of  the  child  and  the  season  of 
the  year  will  permit.  A  change  of  climate  in  many  instances  may  be  ad- 
visable to  avoid  the  extreme  heat  of  summer  and  the  damp  cold  of  winter. 
These  children  should,  as  a  rule,  be  taken  out  of  scliool.  Mental  stim- 
ulation, nervous  excitement  and  all  forms  of  mental  and  physical  fatigue 
should  be  avoided  until  their  physical  and  nervous  condition  justifies  a 
return  to  the  ordinary  routine  of  child-life. 


258     EECURKENT    VOMITING,  CORYZA,    AND    MIGRAINE 


RECURRENT  CORYZA 

There  is  a  form  of  coryza,  recurring  at  irregular  intervals  without  ap- 
parent local  or  external  cause,  which  is  self-limited  and  is  closely  related 
in  its  etiology  and  pathology  to  recurrent  vomiting. 

Symptomatology. — Constipation,  loss  of  appetite,  general  nervous  irri- 
tability and  sallowness  of  skin  may  be  prodromes.  The  attack  itself  comes 
on  with  an  acute  congestion  of  the  nasal  mucous  membrane,  accompanied 
by  a  profuse,  irritating,  thin  mucous  discharge  from  the  nose,  which  pro- 
duces redness  and  swelling  of  the  lip  over  which  it  flows ;  at  the  same  time 
there  is  commonly  an  acute  congestion  of  the  mucous  membranes  of  the 
eyes,  marked  by  a  redness  and  swelling  of  the  conjunctiva,  intense  photo- 
phobia, and  a  profuse  overflow  of  tears.  These  symptoms  come  on  rapidly 
and  are  associated  with  a  state  of  extreme  nervous  irritability.  The  pa- 
tient seeks  a  darkened  room,  buries  her  head  in  the  pillows,  or  shields  her 
eyes  with  her  hands  when  light  is  admitted.  These  attacks  are  self-limited ; 
the  symptoms  continue  in  the  worst  cases  for  four  or  five  days,  and  then 
quickly  subside.  Convalescence  is  very  rapid;  within  two  or  three  days 
after  the  symptoms  begin  to  disappear  the  patient  is  quite  well,  showing 
little  or  no  evidence  of  disease  of  the  mucous  membranes,  which  were  so 
recently  the  site  of  extreme  irritation.  These  attacks  recur  from  time  to 
time  at  irregular  intervals,  very  like  those  of  recurrent  vomiting  and  mi- 
graine, and  in  the  interval  between  the  attacks  there  may  be  no  evidence 
of  disease  of  the  mucous  membranes  of  the  eye  and  nose.  The  above 
description  represents  the  severe  type  of  this  disorder.  In  milder  cases 
the  attack  may  manifest  itself  as  a  more  or  less  severe  coryza  with- 
out the  eye  symptoms,  and  may  in  this  form  occur  as  one  of  the  pro- 
dromes of  an  attack  of  recurrent  vomiting.  Vasomotor  coryza  is  not 
uncommonly  associated  in  its  clinical  manifestations  with  an  urticaria  of 
the  skin. 

The  treatment  in  every  particular  is  similar  to  that  of  recurrent  vom- 
iting. 

MIGRAINE 

Migraine  is  an  autointoxication  due  to  systemic  or  intestinal  toxins 
which  find  expression  in  recurrent  self-limited  attacks  of  severe  paroxysmal 
headaches,  usually  unilateral,  commonly  accompanied  by  nausea,  vomit- 
ing, vertigo,  and  visual  phenomena  and  followed  by  a  profound  sleep  from 
which  the  patient  awakes  free  from  pain. 

Migraine  is  not  often  a  disease  of  early  childhood.  The  great  major- 
ity of  cases  appear  in  late  childhood  or  early  adult  life. 

It  is  very  similar  in  its  etiolog}'  and  pathology  to  recurrent  vomiting. 
It  may,  however,  be  noted  that  reflex  factors  such  as  eye-strain,  diseases 
of  the  nasopharynx  and  of  the  genitourinary  and  pelvic  organs,  play  a 
more  important  role  as  exciting  causes  in  touching  off  an  attack  of  mi- 


MIGRAINE  259 

graine  than  they  do  in  producing  recurrent  vomiting.  I  have  in  a  num- 
ber of  instances  seen  the  recurrent  vomiting  attacks  of  early  childhood 
become  attacks  of  true  migraine  in  late  childhood  and  adult  life. 

The  treatment  of  migraine  occurring  in  childhood  is  similar  to  that 
above  outlined  for  recurrent  vomiting. 


SECTION   VI 

INFECTIOUS  DISEASES 

CHAPTER  XXXIII 
FEVER 

Fever-  is  the  most  common  symptom  of  illness  in  infancy  and  child- 
hood. At  this  period  of  life  there  is  such  a  predisposition  to  fever  that 
high  temperatures  may  occur  from  comparatively  slight  causes,  and  for 
this  reason  the  direct  exciting  cause  of  the  fever  is  not  always  apparent 
at  the  beginning  of  the  child's  illness.  The  physician  must  frequently 
wait  until  the  second  day,  or  perhaps  later,  before  he  can  determine  the 
nature  of  the  pathological  disturbance.  In  the  meantime  he  must  pre- 
scribe for  the  sick  child  and  be  directed  in  the  selection  of  a  diet  and  other 
remedies  along  such  lines  as  his  general  experience  teaches  him  are  the 
safest  and  the  most  likely  to  bring  good  results  under  existing  conditions. 
In  thus  prescribing  for  a  syndrome  of  which  fever  is  the  most  important 
symptom,  the  physician's  judgment  must  be  largely  directed  by  his  knowl- 
edge of  the  most  common  exciting  causes  of  fever  at  different  ages  in  the 
life  of  the  child,  as  well  as  by  the  accompanying  but  as  yet  inconclusive 
symptoms  with  which  the  fever  is  associated.  For  the  above  reasons  an 
inquiry  into  the  most  common  direct  causes  of  fever  at  different  periods 
in  the  life  of  the  child  should  be  of  the  greatest  practical  importance  to 
physicians  in  enabling  them  to  begin  the  treatment  of  these  cases  in  a  way 
to  give  the  most  satisfactory  results. 

In  the  chapter  on  Growth  and  Development  I  have  discussed  the 
physiological  peculiarities  of  the  heat-regulating  mechanism  of  the  young 
nervous  system  and  have  there  shown  that  the  tendency  to  high  fever  from 
comparatively  trivial  causes  at  this  time  of  life  is  due  to  the  marked 
excitability  of  the  thermogenic  centers  and  the  feeble  control  which  the 
inhibitory  centers  exercise  over  them,  and  have  also  called  attention  to  the 
fact  that  the  very  efficient  heat-dissipating  mechanism  of  this  period  of 
life  acts  as  a  protecting  agency,  and  by  its  quick  response  reduces  these 
high  temperatures.  This  rapid  play  of  function  between  the  heat-generat- 
ing and  heat-dissipating  functions  accounts  for  the  great  variability  of  the 
temperature  curve  which  characterizes  the  fevers  of  childhood.  A  sus- 
tained temperature  with  little  variations  is  rarely  seen  in  the  infant  or 

260 


EXCITING    CAUSES    OF    FEVER  261 

child,  except  in  lobar  pneumonia  and  typhoid  fever,  and  even  in  these  we 
have  greater  variations  in  the  temperature  curve  than  we  do  in  the  same 
conditions  in  the  adult.  In  the  same  chapter  I  emphasized  the  fact  that 
the  tendency  of  the  individual  child  to  high  and  variable  temperatures 
might  be  greatly  exaggerated  by  a  neurotic  inheritance,  a  chronic  mal- 
nutrition or  unfavorable  environment.  It  is  evident,  therefore,  that  apart 
from  the  unfinished  and  unstable  condition  of  the  heat-regulating  mechan- 
ism of  the  child,  the  most  important  predisposing  causes  of  fever  are  to 
be  found  in  all  those  conditions  which  produce  the  malnourished  and  ab- 
normally nervous  child.  These  have  been  previously  discussed  in  the 
chapter  on  The  General  Hygiene  of  Infancy  and  Childhood.  This  leaves 
for  OUT  discussion  here  the  direct  exciting  causes  of  fever. 

Exciting  Causes  of  Fever. — The  most  common  exciting  causes  of  fever 
in  infancy  and  childhood  may  be  classified  as  follows : 

1.  Intestinal  toxemia,  commonly  of  bacterial  origin,  but  including  also 
the  "food  injuries"  described  under  Acute  Intestinal  Indigestion. 

2.  Systemic  toxemia  of  bacterial  origin. 

3.  Systemic  autointoxication  of  non-bacterial  origin. 

4.  Heat-stroke. 

5.  Mechanical  and  reflex  irritation,  including  simple  indigestion. 

6.  Muscular  action   (convulsive)   and  over-fatigue. 

Intestinal  toxemia  is  by  far  the  most  common  and  the  most  im- 
portant cause  of  fever  in  children  under  two  years  of  age;  this  is  especially 
true  of  artificially  fed  infants.  This  fact  alone  is  of  the  very  greatest 
importance  in  directing  the  physician  along  proper  lines  of  therapeutic  ac- 
tion. In  a  child  under  two  years  of  age,  especially  if  it  is  being  fed  upon 
artificial  food,  elevation  of  temperature,  the  causes  of  which  cannot  be 
ascertained,  may  be  assumed  to  be  due  to  intestinal  toxemia  and  treated 
accordingly  until  a  positive  diagnosis  can  be  made.  There  are  many  other 
causes  which  may  produce  fever  in  children  at  this  time  of  life,  but  the  fact 
remains  that  under  the  above-named  conditions  a  tentative  diagnosis  of 
gastrointestinal  toxemia  is  shown  by  later  developments,  in  the  great  ma- 
jority of  cases,  to  be  the  true  one,  and  above  all  it  offers  a  safe  and  wise 
course  for  therapeutic  action.  The  influence  of  free  catharsis  and  absti- 
nence from  food  upon  the  temperature  curve  in  these  cases  will  materially 
assist  in  confirming  the  diagnosis.  If  under  these  measures  the  tempera- 
ture falls  and  remains  low,  it  is  a  safe  inference  that  intestinal  intoxication 
was  the  cause  of  the  fever,  but,  if  following  this  treatment  there  is  no  fall 
in  the  temperature,  or  if  following  the  fall  there  is  a  subsequent  rise  of 
the  temperature,  which  is  not  influenced  by  catharsis  and  starvation,  the 
inference  is  that  the  fever  with  its  accompanying  symptom  group  is  due  to 
other  causes  than  intestinal  intoxication. 

Systemic  intoxication  of  bacterial  origin  is  the  most  common 
cause  of  fever  in  children  over  two  years  of  age,  and  the  older  the  child 
the  more  important  becomes  this  factor  as  a  fever  producer.  In  children 
over  three  years  of  age,  an  elevation  of  temperature  without  apparent  cause 


262  FEVER 

commonly  means  the  child  is  suffering  from  tonsillitis,  influenza  (la 
grippe),  pneumonia  or  one  of  the  other  acute  infectious  diseases.  Whatever 
may  be  the  subsequent  course  of  the  temperature  curve  in  the  various 
acute  infections,  they  are  almost  always  announced  by  an  early  rise  in 
temperature,  and  the  distinctive  symptoms  which  complete  the  symptom 
group  and  make  possible  an  accurate  diagnosis  may  not  appear  until  the 
second  or  third  day,  or  even  later.  In  these  cases  it  is  always  wise  to 
isolate  the  sick  child  from  the  well  ones  in  the  family.  A  preliminary 
cathartic,  a  light  diet,  and  some  such  medicine  as  aspirin  or  phenacetin, 
to  control  the  fever  and  nervous  symptoms,  are  indicated  until  the  diag- 
nosis is  made. 

Systemic  autointoxication  of  non-bactekial  origin  plays  a  rather 
important  role  in  producing  fever  in  infants  and  young  children.  The 
fever,  however,  from  this  cause  cannot  be  differentiated  from  that  produced 
by  one  of  the  acute  infections  until  symptoms,  such  as  occur  in  uremia, 
acidosis  and  other  intoxications,  present  themselves  to  complete  the  auto- 
toxic  syndrome.  The  clinical  picture  produced  by  these  conditions  is  else- 
where described  under  Recurrent  Vomiting.  The  preliminary  treatment 
of  these  cases,  even  if  we  knew  from  the  beginning  the  character  of  the 
disease,  would  be  that  of  free  catharsis  and  abstinence  from  food. 

Heat-stroke^  as  Forchheimer  has  long  taught,  is  an  important  cause 
of  fever  in  infancy  and  childhood.  Probably  the  best  explanation  of  the 
fever  of  heat-stroke  is  that  the  feeble  inhibitory  heat  centers  of  the  child 
are  still  further  weakened  by  the  heat,  so  that  practically  no  restraint  is 
exercised  over  the  thermogenic  centers.  This  explains  the  fact  that  the 
younger  the  infant  the  more  prone  is  it  to  have  elevations  of  temperature 
from  exposure  to  excessive  heat.  In  the  premature  infant  the  body  tem- 
perature may  be  raised  far  above  normal  by  the  unwise  application  of 
hot  water  bottles  and  other  forms  of  external  heat.  During  the  summer 
season  many  of  the  so-called  cases  of  cholera  infantum  with  high  temper- 
atures and  other  severe  symptoms  are  due  to  excessive  heat.  In  these  cases 
the  heat  acts  directly  as  a  fever  producer  and  also  indirectly  in  keeping 
up  the  fever  by  producing  a  gastrointestinal  fermentation.  High  fever  in 
a  young  infant  that  has  been  exposed  to  unusual  heat  should  be  attributed 
to  this  cause,  and  should  be  treated  by  ice-bags  to  the  head,  tub-baths, 
free  catharsis  and  abstinence  from  food  until  the  character  and  cause  of 
the  fever  have  been  definitely  determined. 

Direct  mechanical  and  reflex  irritations  may  produce  an  eleva- 
tion of  temperature  in  the  young  infant.  It  is  important  to  remember 
that  a  purely  reflex  fever  may  occur  during  infancy.  These  fevers  are, 
as  a  rule,  evanescent  and  of  comparatively  little  pathological  importance. 
They  occur  very  infrequently  in  normal,  well-nourished  infants,  but  they 
are  of  very  common  occurrence  in  nervous,  malnourished  ones.  The  cut- 
ting of  a  tooth,  undigested  food,  worms,  foreign  bodies  in  the  intestinal 
canal,  and  excessive  pain  (earache)  are  among  the  most  common  causes 
of   reflex   elevations   of  temperature.      Slight   elevations   of   temperature 


OBSCURE    FEVERS    OF    INFANCY    AND    CHILDHOOD   263 

therefore  occurring  in  nervous,  malnourished  infants  may  be  due  to  the 
coming  through  of  a  tooth,  or  to  undigested  food  in  the  intestinal  canal, 
and  elevations  of  temperature  with  violent  and  prolonged  paroxysms  of 
crying  should  lead  to  a  careful  examination  of  the  ear.  The  preliminary 
treatment,  however,  of  these  cases  is  the  same  as  that  previously  outlined 
for  intestinal  toxemia,  and  their  subsequent  history  will  establish  the 
diagnosis  and  direct  more  specific  treatment. 

Excessive  muscular  action  may  cause  an  elevation  of  temperature 
in  infants  and  young  children.  The  manifestation  of  muscular  energy  is 
always  accompanied  by  the  formation  of  heat,  and  excessive  muscular  ac- 
tion, such  as  occurs  in  general  convulsions,  may  be  accompanied  by  an 
increase  in  the  body  temperature;  the  elevation  of  temperature,  therefore, 
at  the  close  of  a  convulsion  may  be  higher  than  at  its  beginning.  This 
cause  of  increased  temperature,  however,  is  of  comparatively  little  impor- 
tance. Over-fatigue  may  cause  an  elevation  of  temperature  in  nervous, 
malnourished  children.  The  rise  in  temperature  from  this  cause  usually 
occurs  in  the  afternoon  and  may  reach  to  101  °F.  A  slight  afternoon  rise 
of  temperature  in  this  type  of  child  should  be  treated  by  fresh  air  and 
rest  for  a  few  days,  and  if  the  fever  still  continues  it  is  due  to  other 
causes. 

In  the  above  study  of  the  causes  of  fever  I  have  attempted  to  furnish 
the  data  which  will  assist  one  in  arriving  at  a  fairly  accurate  determina- 
tion of  the  cause  of  a  fever  occurring  as  the  initial  symptom  of  an  acute 
illness,  and  I  have  also  attempted  to  indicate  the  safe  and  rational  thera- 
peutic measures  with  which  the  treatment  of  acute  febrile  cases  should  be 
begun.  There  is  in  the  obscure  fevers  of  infancy  and  early  childhood  a 
field  of  diagnostic  and  therapeutic  inquiry  quite  as  important  as  that  upon 
which  we  have  just  dwelt.  In  the  "obscure  fevers  "  the  difficulty  in  diag- 
nosis continues  after  the  onset  of  the  initial  symptoms.  In  some  of  these 
cases  the  failure  to  make  the  diagnosis  is  due  to  carelessness,  insufficient 
knowledge,  or  lack  of  facilities  on  the  part  of  the  physician;  in  others 
the  symptoms  and  physical  findings  do  not  form  a  syndrome  sufficiently 
clear  to  warrant  a  definite  diagnosis.  For  these  reasons  it  is  important 
that  the  physician  should  have  constantly  in  mind  the  most  common 
causes  of,  and  tlie  most  rational  treatment  for,  these  "obscure  fevers." 

Obscure  Fevers  of  Infancy  and  Childhood. — Holt's  (inanition)  fe- 
ver is  the  most  common  cause  of  fever  during  the  first  four  or  five  days  of 
life ;  in  fact,  fever  rarely  occurs  at  this  time  from  any  other  cause.  Holt's 
fever  is  a  clearly  defined  syndrome;  the  elevation  of  temperature  usually 
occurs  on  the  second  or  third  day  of  life  and  disappears  by  the  fifth  or 
sixth;  it  requires  no  treatment  other  than  the  giving  of  water  or  breast- 
milk.    It  is  elsewhere  described. 

Sepsis  is  the  most  important  cause  of  fever  during  the  second  week 
of  life.  Continuous  fever  occurring  at  this  time,  not  associated  with  di- 
gestive disturbances,  is  in  the  great  majority  of  instances  due  to  sepsis, 
and  the  septic  infection  commonly  finds  an  entrance  through  the  open  um- 


264  FEVEK 

bilical  wound.  Since  sepsis  in  the  new-born  is  a  disease  of  great  gravity, 
an  unexplained  fever  during  the  second  week  of  life  is  sufficient  cause  for 
alarm  and  demands  tliat  other  symptoms  of  sepsis  should  be  carefully 
looked  for  and  that  the  treatment  for  this  disease  should  be  at  once  in- 
stituted. 

Lobar  pneumonia  is  a  common  cause  of  obscure  fever  in  the  infant. 
The  fever  of  this  disease  is  not  only  high,  but  is  more  sustained  than  that 
of  any  other  fever  of  infancy.  A  high  temperature  curve  that  runs  its 
course  with  little  variation,  occurring  in  an  infant  under  two  years  of 
age,  is  strongly  suspicious  of  lobar  pneumonia.  This  fact  is  important, 
since  in  many  cases  of  lobar  pneumonia  in  the  infant  the  physical  signs 
are  not  discoverable  until  the  fourth  or  fifth  day.  A  sustained  high  tem- 
perature, therefore,  occurring  without  apparent  cause  in  an  infant,  should 
be  treated  as  a  lobar  pneumonia  until  a  definite  diagnosis  is  made. 

Otitis  media  is  perhaps  the  most  common  cause  of  obscure  fever  in 
children  under  two  years  of  age,  and  is  not  an  uncommon  cause  in  older 
children.  The  fever  of  otitis  media  is  subject  to  wide  variations;  at  one 
time  during  the  day  it  may  reach  104°  or  105°F.,  and  at  another  be  almost 
or  quite  normal.  Otitis  media  as  the  cause  of  fever  is  perhaps  more  gen- 
erally overlooked  than  any  other  disease ;  for  this  reason  it  should  be  a  rule 
of  practice  to  examine  the  ear  and  look  for  other  signs  of  otitis  media  in 
all  the  unexplained  fevers  of  infancy  and  early  childhood.  It  is  not  al- 
ways associated  with  earache,  but  when  this  symptom  is  present,  the  violent 
fits  of  crying  should  at  once  call  attention  to  the  ear  as  the  cause  of  trouble. 

Pyelocystitis^  although  nothing  like  so  common  as  pneumonia  or 
otitis  media,  is  not  an  uncommon  cause  of  obscure  fever  in  infancy  and 
early  childhood.  Unless  the  physician  be  on  the  alert,  these  cases  are 
nearly  always  overlooked  and  the  fever  is  attributed  to  some  other  cause. 
The  fever  of  pyelocystitis  is  much  more  irregular  than  that  of  lobar  pneu- 
monia and  very  commonly  there  are  few  or  no  symptoms  to  call  attention 
to  the  genitourinary  organs.  For  this  reason,  unless  the  physician  makes 
it  a  rule  to  examine  the  urine  in  all  the  obscure  fevers  of  infancy  and 
early  childhood,  these  cases  may  run  on  for  weeks  without  attention  being 
called  to  the  bladder  or  kidneys  as  the  site  of  the  infection. 

Tuberculosis  is  the  most  common  cause  of  continued  fever  of  ol)scure 
origin  in  children  over  four  years  of  age.  The  tuberculosis  of  childhood, 
as  I  have  elsewhere  said,  is  usually  concealed,  and  one  of  its  earliest  man- 
ifestations is  a  slight  irregular  fever.  As  the  disease  progresses  the  tem- 
perature may  rise  to  103°  or  104°  F.,  but  it  commonly  falls  to  normal  or 
below  normal  during  the  day.  The  tuberculosis  of  infancy  (that  is  to  say 
under  two  years  of  age)  is  not  a  concealed  disease;  it  runs  a  rapid  and 
much  more  serious  course  and  is  not  commonly  manifested  as  an  obscure 
fever.  In  children,  therefore,  over  four  years  of  age  a  long-continued  ir- 
regular fever,  without  apparent  cause,  should  strongly  suggest  tuberculosis, 
and  the  diagnosis  can  usually  be  confirmed  by  other  signs  and  symptoms 
outlined  in  the  chapter  on  that  disease. 


OBSCURE    FEVERS    OF    INFANCY    AND    CHILDHOOD   265 

Typhoid  fever  is  not  an  uncommon  disease  after  the  second  or  third 
year  of  life.  During  childhood  it  may  he  classed  among  the  obscure  fe- 
vers, since  the  nervous  and  abdominal  symptoms,  which  are  so  character- 
istic in  the  adult,  are  commonly  absent  in  the  young  child.  The  fact  that 
typhoid  fever  in  the  child,  like  lobar  pneumonia  in  the  infant,  is  the  most 
common  cause  of  high  and  sustained  fever  is  very  important  from  a  diag- 
nostic standpoint.  Every  fever  occurring  at  this  period  of  life  that  runs 
a  high  course  with  comparatively  little  variation  should  be  tentatively 
diagnosed  as  typhoid  and  treated  as  such  until  further  developments  make 
the  diagnosis  clear.  The  Widal  reaction  commonly  makes  the  diagnosis  in 
these  cases,  but  even  in  the  presence  of  a  negative  Widal  the  case  should 
be  treated  as  typhoid  until  other  causes  for  the  fever  are  discovered.  In 
some  instances  the  Widal  test  is  not  positive  until  the  second  or  third  week 
of  the  disease,  and  then  again  there  is  a  group  of  cases  produced  by  the 
paratyphoid,  the  bacillus  enteritidis,  and  perhaps  other  organisms,  which 
have  all  the  clinical  characteristics  of  typhoid  fever  and  yet  never  show 
the  Widal  reaction. 

Subacute  and  chronic  intestinal  toxemia  may  be  the  cause  of 
obscure  fever  in  infancy  and  early  childhood.  In  these  cases  a  temperature 
from  101°  to  101i/2°F.  may  be  present  in  the  afternoon  with  a  normal  or 
subnormal  temperature  in  the  morning,  and  there  may  be  little,  on  casual 
examination,  to  call  attention  to  the  intestinal  canal  as  the  cause  of  the 
disturbance.  On  closer  inspection,  however,  it  will  be  found  that  the  in- 
testinal discharges  are  not  normal.  They  may  be  fragmentary,  putrid, 
and  covered  with  more  or  less  mucus,  and  an  examination  of  the  urine  will 
show  a  marked  increase  in  indican  or  indolacetic  acid.  Suitable  cathartics 
from  time  to  time  with  a  carefully  regulated  diet  will  control  the  temper- 
ature if  intestinal  toxemia  is  the  exciting  cause. 

Septic  infection  is  not  an  uncommon  cause  of  obscure  fever  through- 
out childhood.  The  temperature  curve  of  sepsis,  which  runs  from  103°  to 
105°  F.  at  one  time  during  the  day  and  falls  to  96°  or  97°  F.  at  another, 
is  so  suggestive  of  sepsis  that  septic  infection  is  commonly  suspected  with 
this  type  of  temperature,  although  the  localization  of  the  sepsis  may  be 
very  obscure.  In  these  cases  the  presence  of  an  increasing  polynuclear 
leukocytosis  may  confirm  the  diagnosis.  If  an  examination  of  the  ear 
excludes  otitis  media,  the  bronchial  or  cervical  lymphatics  or  the  mastoid 
may  be  suspected  as  the  possible  site  of  the  sepsis.  In  older  children  the 
antrum  or  frontal  sinus  may  harbor  the  infection,  and  in  some  cases  we 
may  have  a  general  septicemia  which  runs  its  course  to  a  fatal  or  favor- 
able termination  without  apparent  localization.  In  the  great  majority  of 
instances  septic  infection  in  infancy  and  childhood  occurs  as  the  sequel 
or  as  a  complication  of  one  of  the  acute  infectious  diseases;  under  such 
conditions  the  physician,  being  prepared  for  the  development  of  septic 
symptoms,  rarely  fails  to  make  the  diagnosis,  although  he  may  have  trouble 
in  locating  the  focus  of  infection. 

Treatment. — In  the  treatment  of  obscure  fevers  it  is  wise  to  begin 


266  FEVEE 

with  a  cathartic  such  as  small  doses  of  calomel  followed  by  castor  oil. 
This  preliminary  clearing  of  the  intestinal  canal  can  do  no  harm  in  any 
form  of  fever  and  is  of  value  in  reducing  the  temperature  even  though  the 
intestinal  canal  be  not  the  site  of  the  disease.  Throughout  the  course  of 
the  fever  the  intestinal  canal  should  receive  careful  attention;  constipa- 
tion, intestinal  fermentation  and  diarrhea  are  to  be  treated  by  appropriate 
remedies,  whatever  may  be  the  cause  of  the  fever. 

j)iet. — A  fluid  diet,  free  from  milk  or  other  albuminous  foods,  should 
be  prescribed  for  the  first  twenty-four  or  thirty-six  hours,  or  until  it  has 
been  determined  that  intestinal  intoxication  is  not  the  cause  of  the  fever. 
In  children  over  three  years  of  age  having  a  sustained  temperature,  a 
typhoid  diet  should  be  prescribed  until  it  is  proven  that  the  disease  is  not 
typhoid;  this  rule  will  prevent  many  gross  dietetic  errors.  Jacobi  says: 
"In  ordinary  fevers  the  food  must  be  liquid  and  rather  cool ;  in  vomiting, 
cold;  in  respiratory  diseases,  warm;  in  collapse,  hot.  The  best  feeding 
time  is  the  remission;  in  intermittent  fevers  nothing  must  be  given  dur- 
ing the  attack  except  water,  or  acidulated  water,  now  and  then  with  an 
alcoholic  stimulant;  in  septic  fevers,  nothing  during  a  chill,  except  either 
cold  or  hot  water,  according  to  the  wishes  of  the  patient,  with  alcoholic 
stimulant.  Common  ephemeral  catarrhal  fevers  may  do  without  food  (ex- 
cept water)  for  a  reasonable  time.  Sleep  must  not  be  disturbed,  except 
in  conditions  of  sepsis  and  depressed  brain  action.  In  both  there  is  no 
sound  sleep,  but  sopor,  which  should  be  interrupted.  In  sepsis  this  rous- 
ing from  sopor  is  an  absolute  necessity.  Unless  they  are  aroused  fre- 
quently to  be  fed  sufficiently  and  stimulated  freely,  the  patients  will  die. 
Besides,  in  most  of  the  cases  the  temperatures  are  not  high,  and  there  is  no 
contraindication  to  feeding  on  that  account.  Chronic  inflammatory  fe- 
vers bear  and  require  feeding  as  generous  as  it  must  be  careful." 

Antipyretics. — The  ice-bag  not  too  closely  applied  to  the  head  is  one 
of  the  most  valuable  measures  we  have  for  the  control  of  high  tempera- 
tures in  the  infant  and  child.  In  the  application  of  this  remedy,  however, 
it  is  necessary  that  the  patient  should  be  under  the  observation  of  a  com- 
petent nurse,  since  there  is  some  danger  in  very  young  and  delicate  in- 
fants that  the  prolonged  application  of  ice  to  the  head  may  produce  a  sub- 
normal temperature.  This  should  be  guarded  against  by  careful  tempera- 
ture records,  so  that  when  the  temperature  approaches  normal  the  ice-bag 
may  be  removed;  in  older  children  this  danger  does  not  exist.  The  ice- 
bag  when  properly  applied  is  not  only  a  satisfactory  antipyretic  measure, 
but  it  exercises  a  very  pronounced  influence  over  the  nervous  symptoms 
which  accompany  the  fever.  The  bath  is  the  safest  and  most  effective 
agency  we  have  for  reducing  the  body  temperature.  It  is  important  to 
remember  that  the  cold  bath  does  not  always  act  as  kindly  in  infants  as 
it  does  in  older  children.  Frail  and  nervous  infants  do  not  react  well 
from  the  cold  bath;  the  shock  to  the  nervous  system  produced  by  the 
sudden  application  of  cold  water  to  the  body  may  do  more  harm  than 
good.     The  temperature  of  the  bath  must  be  regulated  by  the  age  and 


ETIOLOGY  267 

strength  of  the  infant.  In  young  and  delicate  infants  a  warm  or  tepid 
bath,  or  a  sponge  bath  with  alcohol  and  warm  water,  will,  when  combined 
with  the  use  of  the  ice-bag  in  the  interval  between  the  baths,  reduce  the 
body  temperature  and  exercise  a  sedative  influence  on  the  nervous  system. 
In  older  and  sturdier  children  cool  baths  and  cold  packs  may  be  given 
with  signal  advantage,  but  it  is  rarely  necessary  to  use  a  bath  below  80° F. 
Phenacetin  and  aspirin  in  doses  suited  to  the  age  of  the  child  may  be 
safely  used  for  the  control  of  the  temperature  in  the  early  stages  of  the 
ephemeral  fevers  of  childhood.  These  medical  antipyretics  should  be  used 
only  during  the  first  twelve  or  twenty-four  hours  of  the  fever  and  then 
only  for  controlling  unusually  high  temperatures  which  are  associated 
with  marked  nervous  symptoms.  They  should  not  be  used  in  the  prolonged 
fevers  associated  with  marked  prostration.  Fever  patients  should,  if  pos- 
sible, be  put  to  bed  and  kept  there  until  the  temperature  has  reached 
normal.  They  should  also  be  isolated  from  other  children  and  shielded 
from  all  unnecessary  excitement. 


CHAPTER   XXXIV 
TYPHOID   FEVER 

Typhoid  fever  is  an  acute  infectious  disease  caused  by  the  typhoid 
bacillus.  It  is  a  general  infection  characterized  by  a  more  or  less  typical 
temperature  curve,  and  by  the  involvement  of  lymphoid  tissues,  especially 
Peyer's  patches  and  the  spleen. 

Etiology. — The  typhoid  bacillus,  which  is  the  specific  cause  of  this 
disease,  was  first  described  by  Eberth.  It  is  cylindrical  with  rounded  ends, 
crowned  with  cylia,  and  is  from  1  to  3  ju  in  length  and  from  .5  to  .8  fx 
in  diameter.  It  has  marked  motility  in  liquid  media  and  grows  readily  at 
body  temperature  in  common  culture  media.  It  is  destroyed  at  140°  F., 
but  resists  low  temperatures;  it  can  live  for  months  in  ice  and  in  ordinary 
drinking  water.  On  clothing  soiled  with  typhoid  feces  or  urine  the  bacilli 
may,  if  not  exposed  to  light  and  desiccating  processes,  live  for  weeks.  This 
extraordinary  vitality  under  adverse  circumstances  enables  it  to  live  and 
thrive  in  every  part  of  the  globe  from  the  tropics  to  the  Arctic  regions ;  it 
is  therefore  practically  a  world-wide  disease.  It  is  but  slightly  pathogenic 
for  other  animals  than  man;  Grunbaum  has  produced  the  disease  in  chim- 
panzees. Other  living  creatures  may  harbor  the  bacilli  in  their  intestinal 
canals  and  elsewhere,  and  act  as  typhoid  carriers,  even  though  they  present 
no  symptoms  of  typhoid  fever.  The  typhoid  bacillus  is  to  be  distinguished 
from  a  group  of  similar  organisms  to  which  it  belongs,  such  as  the  bacillus 
enteritidis,  the  colon,  and  the  paratyphoid  bacillus  A  and  B,  all  of  which 
are  capable  of  producing  clinical  syndromes  closely  simulating  typhoid 
fever.  The  bacillus  enteritidis  and  the  paratyphoid  B  are  believed  to  be 
the  chief  causes  of  meat-poisoning. 


268  TYPHOID    FEVER 

Source  of  Inf ection.  — 1 1  is  a  generally  admitted  fact  that  the  intestinal 
canal  and  lymphoid  tissues  of  man  furnish  the  most  favorable  culture 
conditions  for  the  growth  of  the  typhoid  bacilli.  The  tendency  is  to  an 
increase  in  virulence  as  the  bacilli  pass  from  host  to  host  in  the  course  of 
an  epidemic,  so  that  the  early  cases  may  be  mild  and  the  later  ones  severe. 

Method  of  Infection. — Drinking  water,  contaminated  by  the  fecal  or 
other  discharges  from  typhoid  patients,  is  tlie  common  cause  of  the  spread 
of  this  disease.  Wells,  or  the  general  water  supply  of  cities,  may  be  con- 
taminated by  sewage  and  thus  cause  epidemics  of  typhoid  fever.  Too  much 
stress  cannot  be  laid  upon  the  importance  of  contaminated  drinking  water 
as  the  great  cause  of  typhoid  fever.  Milk,  being  a  good  culture  media, 
may  be  a  carrier  of  this  infection ;  many  small  epidemics  have  been  traced 
to  this  source.  In  such  instances  the  milk  is  usually  contaminated  by 
an  infected  water  supply,  the  water  being  used  in  diluting  the  milk  or 
washing  the  pails.  Ice-cream  made  from  contaminated  milk  may  produce 
typhoid  fever. 

Flies  may  act  as  carriers  of  typhoid  infection  to  milk  and  other  food 
materials  of  man.  The  danger  from  the  fly  is  greatest  in  country  districts 
and  where  large  bodies  of  people  are  camping  under  conditions  which  per- 
mit it  to  come  in  contact  with  fecal  discharges ;  in  the  city,  where  sanitary 
plumbing  prevails,  it  has  fewer  o])portunities  to  act  as  a  carrier.  Shell- 
fish, especially  oysters  and  clams  which  are  eaten  raw,  may  be  a  source 
of  infection  when  contaminated  by  sewer  discharges.  The  contagion  is 
rarely,  if  ever,  carried  through  the  air;  the  surroundings  of  the  patient, 
except  as  they  are  fouled  by  excretory  discharges,  are  not  a  source  of  dan- 
ger; direct  infection,  however,  does  occur  to  nurses  and  others  who  are  in 
close  contact  with  the  patient,  but  such  infection  is  avoidable  if  proper 
methods  of  cleanliness  and  disinfection  are  used  in  the  care  of  the  pa- 
tient. The  contaminated  bed-clothing,  if  not  properly  disinfected,  may  be 
a  source  of  danger  to  the  laundress  or  to  the  household  into  which  it  is 
carried.  Well  individuals  who  have  had  typhoid  fever  may,  in  rare  in- 
stances, harbor  in  their  intestinal  canals  typhoid  bacilli  and  thus  act  as 
typhoid  carriers,  unconsciously  spreading  contagion  among  those  with  whom 
they  come  in  close  contact. 

Occurrence. — Typhoid  fever  occurs  most  commonly  during  the  months 
of  August,  September  and  October ;  Osier  calls  it  an  autumnal  fever.  Dur- 
ing the  first  3'ear  of  life  it  is  comparatively  rare,  and  in  the  second  year 
it  still  remains  a  rather  uncommon  disease,  but  thereafter  susceptibility 
rapidly  increases  up  to  the  twentieth  year. 

Pathology. — Typhoid  fever  is  a  general  infection;  the  bacilli  of  this 
disease  may  be  found  in  every  part  of  the  body.  They  are  present  in  the 
intestinal  canal,  the  blood,  the  rose-spots,  all  the  viscera  and  especially  in 
the  spleen,  mesenteric  glands  and  gall  bladder.  The  lesions  produced, 
while  similar  to  those  found  in  the  adult,  are  much  less  pronounced  and 
extensive.  The  solitary  follicles  and  Peyer's  patches  are  enlarged  and  may 
be  ulcerated.     The  spleen  is  greatly  enlarged,  in  nearly  every  instance 


SYMPTOMATOLOGY  269 

being  two  or  three  times  its  normal  size.  Slight  parench3'matous  degen- 
eration of  the  liver  and  kidneys,  myocardial  weakness,  hyperemia  and  even 
inflammation  of  the  meninges,  pneumonia,  middle  ear  suppuration  and 
parotid  abscess  may  occur.  As  a  rule  the  older  the  child  the  more  nearly 
does  the  pathological  anatomy  conform  to  that  of  the  adult  type,  and  the 
younger  the  child  the  more  important  is  the  typhoid  septicemia. 

Fetal  Typhoid. — The  bacilli  of  typhoid  fever  may  pass  from  the  mother 
through  the  placental  circulation  to  the  fetus;  in  about  one-half  of  these 
cases  abortion  or  premature  labor  results,  and  the  fetus  is  born  dead;  in 
other  cases  the  child  is  born  with  typhoid  fever  of  the  septicemic  type, 
and  death  commonly  results  within  the  first  week ;  fetal  typhoid  is  a  disease 
with  very  great  mortality;  few  cases  recover.  On  the  other  hand,  newly- 
born  infants,  born  of  mothers  who  have  had  typhoid  fever  during  the 
period  of  their  gestation,  may  show  the  Widal  reaction ;  in  such  cases  it  is 
probable  that  the  child  had  typhoid  fever  in  utero  or  that  the  agglutinating 
principle  in  its  blood  was  received  through  the  placental  circulation. 

Period  of  Incubation. — The  Spanish-American  Commission  found  that 
the  average  period  of  incubation  for  typhoid  fever  was  ten  and  a  half  days. 
In  a  study  of  a  local  epidemic  which  I  reported  in  1901,  nine  days  was 
the  shortest  and  nineteen  days  the  longest  period  of  incubation;  the  ma- 
jority had  an  incubation  period  of  less  than  ten  days. 

Symptomatology. — General  Symptoms. — While  in  a  general  way  the 
sj'mptoms  of  typhoid  fever  in  the  child  resemble  those  in  the  adult,  yet  it 
should  be  remembered  that  the  younger  the  child  the  more  are  these  symp- 
toms modified  in  their  course  and  in  their  severity,  so  that  the  symptom- 
complex  is  radically  diiferent  from  that  of  the  adult.  In  the  very  young 
infant  there  is  a  general  typhoid  septicemia  without  marked  local  symp- 
toms, but  as  the  child  grows  older  the  clinical  syndrome  gradually  changes, 
giving  more  and  more  prominence  to  the  characteristic  symptoms  as  they 
occur  in  the  adult.  It  may  also  be  said  that  the  younger  the  child  the 
more  irregular  the  onset  of  this  disease;  in  infancy  it  may  be  marked  by 
acute  prostration,  vomiting,  sudden  rise  of  temperature  and  all  the  evi- 
dences of  a  sudden  and  general  toxemia.  In  such  instances  typhoid  fever 
may  not  be  suspected  until  the  symptoms  of  the  acute  toxemia  have  sub- 
sided, leaving  a  continuous  fever  with  other  symptoms  which  suggest  the 
possibility  of  this  disease.  In  children  three  or  four  years  of  age  the  on- 
set is  commonly  marked  by  headache,  a  general  infection  and  a  gradual 
rise  of  temperature.  The  severity  of  the  disease  cannot  be  predicted  from 
the  suddenness  or  violence  of  the  onset.  The  course  of  typhoid  fever  in 
young  children,  if  not  prolonged  by  complications,  is  mild  and  brief 
as  compared  with  that  in  the  adult;  under  three  years  of  age  it  may  not 
extend  over  fourteen  days;  in  80  eases  observed  by  Henoch,  11  lasted  less 
than  ten  days,  26  less  than  fifteen  days,  16  less  than  twenty  days,  21  from 
twenty  to  thirty  days,  and  6  over  thirty  days. 

Fever. — The  temperature  curve  in  childhood  is  not  so  regular  and 
characteristic  as  it  is  in  the  adult.    The  first  stage  may  be  short,  the  tern- 


270 


TYPHOID    FEVER 


perature  rising  rapidly  to  its  maximum  within  two  or  three  days,  and  the 
third  stage  or  the  stage  of  decline  may  he  marked  by  great  variations, 
the  temperature  assuming  a  markedly  remittent  or  even  intermittent  type, 
while  the  second  stage  may  show  an  almost  continuous  temperature  with 
little  variation  between  the  morning  and  evening  temperature  (Morse). 
In  very  young  children  this  sudden  rise  of  temperature  Avith  the  onset  of 
the  disease  and  its  rapid  fall  toward  the  close  may  not  be  a  matter  of  prog- 
nostic importance,  but  in  older  children  a  sudden  fall  of  temperature  oc- 
curring during  the  height  of  the  disease  should  suggest  perforation  or  in- 
testinal hemorrhage.  Secondary  rises  in  the  temperature  after  the  disease 
has  apparently  run  its  course  may  result  from  relapse  or  from  some  com- 


ofSonth      10      II      12     13      14      15     16      17      18      19     20      21     22     23     24     25     26     27 

OFolsEAse       1        2       3      4       5       6       7       8       9       10      II      12      13     14      15      16      17      18 

107' 

3 

f;::::::f:s:::i;x5:::::i:::::::::::: 

L.,.-L-U:  .V^i. -u-fti 

i              /  W                                 t^    ^ 

^  li  t::::::::::::::^:M  "^iTr" 

i^.h.us^i: 

08'                                                           i    ^    2   I 

97° 

PutsE       ?  ?  ?  ?  ?  ?  1  ?  2  ?  5  5  :  ?  5  1  ?  r  ?  ?  §  ?  !  ?  !  1  !  ?  1  ?  ;  ?  1  ^  s  ^ 

RESPIRATION  ssssssgs?sss:£sssss;sssssssss;a;ssss 

Fig.  42.— Typhoid  Fever  in  Child  Two  and  One-half  Years  of  Age. 

plication.     Very  mild  cases  of  typhoid  fever  running  a  short  and  almost 
afebrile  course  are  more  frequently  observed  in  children  than  in  adults. 

The  pulse,  which  in  the  adult  is  so  valuable  a  prognostic  sign,  is  not  of 
such  great  importance  in  the  young  child.  A  dicrotic,  rapid  and  intermit- 
tent pulse  occurring  during  the  height  of  the  disease,  in  the  adult,  is  a 
danger  signal  of  great  importance.  In  very  young  children  a  pulse  of  170 
may  occur  and  not  be  of  serious  import.  In  older  children  the  pulse  is 
commonly  slow,  varying  from  70  to  90,  but  even  at  this  age  dicrotism  and 
intermittency  do  not,  as  a  rule,  presage  danger.  On  the  whole,  therefore, 
much  less  information  is  obtained  from  a  study  of  the  pulse  in  children 
than  in  adults.  Systolic  murmurs  at  the  apex  and  rarely  at  the  base  are 
common;  they  usually  appear  in  the  third  week  of  the  disease  as  the  acute 


SYMPTOMATOLOGY 


271 


symptoms  subside,  <and  many  continue  for  weeks  after  convalescence  has 
been  established. 

The  exanthem  consists  of  slightly  elevated  rose-spots  about  the  size  of 
a  pin's  head,  which  disappear  on  pressure.  These  spots  are  distributed 
over  the  abdomen  and  back ;  in  some  cases  being  few  in  number  and  widely 
scattered,  in  others  more  numerous  and  grouped  in  patches.  They  com- 
monly appear  from  the  fifth  to  the  eighth  day,  but  may  occur  earlier  or 
later.  In  rare  instances  they  may  assume  a  dark  blue  or  hemorrhagic  ap- 
pearance. In  some  instances  an  erythema  may  precede  this  typical  ex- 
anthem, but  is  of  no  special  importance,  except  that  it  may  complicate  the 
diagnosis.     Sudamina  may  be  present;  toward  the  close  of  the  disease  fine 


OF  MONTH       20     21      22     23     24     25     26      27     28     29     30      31       1       2       3      4       5       6        7       8       9       10 

or  DISEASE        <       2       3       4       5       6       7       8       9       10      II      12      13      14      15      16      17      18      19     20     21      2? 

107" 

f  ,„. L_i .  

1 ,02^     J  L  >  h  ^  h^^    h  ^  L-^  L  h 

r:  r J^LLi/i?L,,.L ..,., 

1     .,-„..........     ..y.Jl  J_T_..- 

t  / lJ1__  A -,___. 

I :  T_|    ..y_:.LS_£v- 

«■                                                                                     lit    w 

PULSE         1  s  s  s  ;  5  g  S  S  .  8  2  I  ;  ?  ;  s  1  S  g  s  s  s^  H  1  s  g  J  2  ;  S  H  2  §  2  s  ?  s  s  5  s  s  s  s 

RESPIRATION     s;8S8SSS;;;:RSSSSS8SSSSSS?SaS5S8S8SlSS?S8S!:S 

Fig.  43. — Typhoid  Fever;  Child  Six  Years  of  Aoe. 


desquamation  occurs.  In  protracted  cases  furunculosis,  or  small  subcu- 
taneous abscesses,  may  be  widely  distributed  over  the  body  and  greatly  add 
to  the  discomfort  of  the  patient,  prolonging  the  disease. 

Enlargement  of  the  spleen  is  almost  always  present  in  typhoid  fever; 
it  begins  early  in  the  disease  and  gradually  increases  to  three  or  four  times 
its  natural  size.  It  can  commonly  be  made  out  by  palpation  on  the  third 
or  fourth  day,  and  for  this  reason  is  of  very  great  diagnostic  value.  It 
gradually  subsides  with  the  other  acute  symptoms,  but  it  can  very  com- 
monly be  demonstrated  after  convalescence  has  been  established ;  in  relapses 
it  again  increases  in  size. 

Digestive  Tiiact. — Abdominal  Symptoms. — Vomiting  occurs  much 
more  frequently  in  children  than  in  adults  and  is  one  of  the  early  symp- 
19 


272 


TYPHOID  FEVER 


toms.  Constipation  is  common,  especially  between  the  ages  of  three  and 
seven,  and  is  usually  obstinate  enough  to  require  laxative  medicines  for  its 
relief.  It  is  very  frequently  associated  with  gastrointestinal  toxemia, 
which  aggravates  and  prolongs  the  disease.  In  quite  young  children 
typhoid  fever  may  begin  with  a  sharp  diarrhea  resembling  an  acute  in- 
testinal toxemia;  in  these  cases,  however,  the  intestinal  irritation  may 
quickly  subside  and  the  subsequent  course  of  the  disease  be  marked  by  a 
mild  diarrhea  or  even  by  constipation.  In  older  children  diarrhea  is 
the  rule,  the  discharges  being  frequent  and  having  the  characteristic  pea- 
soup  appearance.  Meteorism  is  rarely  a  marked  symptom  in  the  young 
child ;  in  older  children  it  may  render  difficult  the  palpation  of  the  spleen 
and  the  percussion  of  liver  dullness.     In  the  young  child  abdominal  pain 


Fig.  44. — Typhoid  Feveb;  Child  Ten  Years  of  Age. 

is  not  usually  present,  and  gurgling  and  tenderness  in  the  right  iliac  region 
cannot  commonly  be  made  out. 

Intestinal  hemorrhage  and  intestinal  perforation  are  very  rare  under 
six  years  of  age.  From  the  tenth  to  the  fifteenth  year,  however,  they  are 
not  so  uncommon  and  are  marked  by  the  same  symptoms  as  in  the  adult. 

The  tongue  is  white,  but  the  tip  and  edges  are  clean  and  dark  red  in 
color;  later  the  coating  gradually  disappears  from  before  backward,  giv- 
ing it  a  bright  red  appearance  with  dark  red  papillae  standing  out  prom- 
inently. The  dry,  fissured,  dark,  coated  tongue  covered  with  sordes  is 
rarely  seen  in  the  child  and  can  be  much  more  readily  prevented  by  mouth 
disinfection  in  the  child  than  it  can  be  in  the  adult. 

Nervous  Symptoms.— The  nervous  symptoms  of  the  child  differ 
markedly  from  those  of  the  adult;  they  are  much  less  common  and  much 
less  severe ;  the  low  muttering  delirium  and  the  profound  stupor  are  rarely 
observed.  In  the  vast  majority  of  cases  the  nervous  symi)toms  are  confined 
to  headache,  restlessness,  irritability,  apathy  and  perhaps  a  tendency  to 
somnolence,  mild  delirium,  and  transitory  delusions.  It  should,  however, 
also  be  noted  that  the  following  nervous  symptoms,  although  very  unusual. 


THE  GIIUBEK-WIDAL  REACTION  273 

may  occur :  convulsions,  stupor,  meningism,  neuritis,  hemiplegia,  aphasia, 
melancholia  and  acute  mania. 

Respiratory  Tract. — Epistaxis,  one  of  the  early  symptoms  of  adult 
typhoid,  is  rare  in  the  child, 

A  mild  bronchitis  is  common  in  typhoid  fever.  Brotwho  and  lobar 
p7ieumonia  are  serious,  but  rare  complications. 

Urine. — The  diazo  reaction  of  Ehrlich  occurs  in  60  to  80  per  cent, 
of  the  cases ;  it  makes  its  appearance  about  the  end  of  the  second  week  and 
increases  in  intensity  while  the  disease  is  at  its  height.  Its  value  as  a 
diagnostic  sign  is  impaired  by  the  fact  that  it  is  found  in  measles,  tuber- 
culosis, malaria,  meningitis,  pneumonia,  and  some  of  the  other  acute  in- 
fections ;  it  is  absent,  however,  in  influenza.  Acetonuria  may  occur.  Acute 
nephritis  is  rare,  but  a  trace  of  albumin  is  not  uncommon. 

Blood. — Simple  anemia  gradually  develops  with  a  like  reduction  in 
corpuscles  and  hemoglobin.  The  leukocytes  progressively  diminish  in  num- 
ber; in  severe  cases  they  may  be  reduced  to  2,000.  The  differential  count 
shows  a  relative  increase  in  mononuclears  and  decrease  in  polymorphonu- 
clears and  eosinophiles.  An  increase  in  leukocytes  to  over  10,000  indicates 
some  form  of  septic  or  inflammatory  complication. 

The  Gruber-Widal  Reaction. — This  is  the  most  valuable  of  all  signs  or 
symptoms  in  the  diagnosis  of  typhoid  fever.  It  is  perhaps  less  accurate 
than  blood  cultures,  but  the  simplicity  of  its  technique,  bringing  it  within 
the  scope  of  the  general  practitioner,  gives  it  a  value  in  diagnosis  which 
perhaps  will  never  be  obtained  by  blood  cultures.  This  reaction  depends 
upon  the  fact  that  the  defensive  mechanism  of  the  body,  in  its  antagonism 
to  typhoid  bacilli,  produces  certain  substances  called  agglutinins,  which 
have  the  power  of  agglutinating  and  rendering  motionless  the  typhoid 
bacillus.  If  the  blood  of  a  typhoid  fever  patient,  containing  these  ag- 
glutinins, be  combined  with  a  bouillon  culture  of  typhoid  bacilli,  it  will 
readily  clump  them  and  stop  their  motion.  When  this  occurs  the  test  is 
said  to  be  positive.  It  is  commonly  made  under  the  microscope,  but 
macroscopic  tests  have  also  been  devised.  The  Gruber-Widal  reaction  is 
perhaps  a  more  valuable  diagnostic  sign  in  children  than  in  adults,  as  it 
occurs  earlier  in  the  disease  and  in  a  larger  percentage  of  cases.  In  the 
average  it  may  be  said  to  occur  in  95  per  cent.,  and  is  commonl}^  found  as 
early  as  the  seventh  or  eighth  day.  This  reaction  continues  for  a  long  time 
after  the  patient  has  recovered  from  typhoid,  so  that  a  positive  Widal  may 
date  from  a  previous  attack.  In  estimating  the  diagnostic  value,  there- 
fore, of  this  test,  care  must  be  taken  to  determine  whether  the  patient  has 
ever  had  typhoid  fever ;  with  this  excluded  a  positive  Widal  associated  with 
an  otherwise  unexplained  acute  febrile  condition  justifies  the  diagnosis 
of  typhoid.  A  positive  Widal  reaction  may  occur  in  jaundice,  but  so  rarely 
in  other  -conditions  as  to  be  practically  negligible.  A  negative  Widal 
reaction  does  not  necessarily  preclude  the  diagnosis  of  typhoid,  as  the  ex- 
amination may  have  been  made  before  the  agglutinins  have  developed  in 
suflicient  quantities  to  produce  a  reaction,  or  the  case  may  belong  to  that 


274 


TYPHOID    FEVEE 


small  percentage  in  which  the  reaction  never  occurs.  Blood  cultures  nearly 
always  give  definite  information  of  the  existence  of  typhoid  before  a  posi- 
tive Widal  can  be  obtained.  At  the  present  time,  however,  this  method  of 
diagnosis  is  largely  confined  to  hospital  practice.     In  this  examination  a 

bouillon  culture  material  is  in- 
oculated with  blood  obtained 
from  a  vein  in  the  arm  and 
after  twelve  or  twenty-four 
hours  is  examined  for  typhoid 
bacilli.  As  the  laboratories 
in  our  cities  become  better 
equipped  and  the  technique  of 
the  operation  simplified,  this 
method  of  diagnosis  may  be- 
come more  generally  used  in 
private  practice. 

Relapses. — Eelapses  occur 
in  from  10  to  15  per  cent,  of 
the  cases;  Blackader  reports 
fifteen  relapses  in  100  cases; 
second  and  even  third  relapses 
may  occur.  Comby  reports  a 
case  with  six  relapses  lasting 
in  all  four  months.  They  may 
occur  about  the  time  a  nor- 
mal temperature  has  been 
reached;  there  is,  however, 
usually  an  intervening  afebrile 
period  of  from  five  to  ten  days. 
The  relapse  commonly  runs  a 
shorter  and  milder  course  and 
is  attended  with  little  danger. 
Complications. — P  a  r  o  t  i  tis 
may  occur  during  the  second 
or  third  week  and  may  result 
in  abscess  of  the  parotid 
gland;  careful  mouth  disin- 
fection diminishes  the  fre- 
quency of  this  complication. 
Furunculosis,  otitis  media, 
pneumonia,  deep-bone  ab- 
scesses, arthritis  and  menin- 
gitis may  occur,  and  a  latent 
tuberculosis  may  become  ac- 
tive. Within  the  last  two 
years  I  have  seen  two  cases  of 


- 

«" 

__■ 

1 1 

- 

-1 

■"~ 

^"^ 

7T7" 

ot 

> 

0>l 

tl 

s 

oo 

^ 

Oil 

-' 

on 

ti 

g 

^ 

OZl 

^»« 

on 

»i 

gs 

CO 

■ 

^ 

fiZt 

01 

C4 

to 

T 

U«i 

£6 

s, 

«Cl 

8e 

c* 

5 

H^ 

t{ 

-J 

oei 

>c 

5 

^ 

fb 

82 

— i*" 

9ft 

at 

s 

C* 

•IE 

■" 

•^ 

-^ 

n  t 

0» 

n 

^ 

■j 

>• 

02 1 

ue 

-• 

■^ 

0£t 

>s 

s: 

5 

UZ^ 

<l 

^ 

»£» 

CE 

c^ 

eo 

aoi 

*»« 

— 

9 

Oti 

*¥ 

C4 

^ 

80 1 

e& 

^ 

Or* 

>i 

o 

n 

= 

«0i 

cc 

a 

• 

09  4 

tit 

52 

- 

on 

n 

^ 

m 

bei 

oc 

E: 

s 

fm^ 

Oil 

ai 

— 

s 

V 

on 

8C 

2 

s 

m 

OUi 

•n 

' — 

~ 

u 

oti 

»fi 

£ 

C5 

^ 

- 

OOt 

*£ 

KU 

oe 

2 

55 

n 

■^" 

OOt 

>< 

J> 

88 

Oi 

CO 

« 

•< 

tfOt 

OE 

2b 

n 

c« 

m 

Oi  1 

>£ 

-i* 

02 1 

a£ 

- 

s 

^ 

00  i 

<E 

f=- 

021 

2 

g 

0€i 

SE 

»0l 

iC 

o> 

C4 

^ 

82 1 

8« 

~^ 

m 

00 1 

oo 

s 

001 

8i 

^ 

L 

Oil 

ot 

r. 

s 





- 

1 — 

021 

r-t 

CO 

a" 





L__. 

— 

- 

1 

oiT 

""51" 

»• 

set 

£C 

in 

801 

01 

— 

- 

^^1* 

2tt 

Si 

^ 

s 

2ei 

£E 

•^ 

* 

211 

it 

CO 

s 

001 

•  i 

- 

■; 

^t* 

08 

Oi 

c« 

s 

08 

02 

001 

82 

- 

o> 

~ 

£il 

82 

- 

— -^ 

>9 

S2 

« 

flO 

Ot  1 

»e 

' 

- 

^    - 

06 

»2 

s 

;r 

' 

021 

»2 

. — 

90> 

»£ 

s 

CO 

^-* 

■ 

>0l 

»2 

' 

—  -^ 

901 

82 

gs 

"S 

Ot  1 

oe 

B« 

»a 

•ii 

s 

2 

001 

26 

^» 

Sll 

82 

s 

CO 

OOi 

82 

>0t 

2E 

s 

c* 

OOI 

»2 

-^ 

^ 

20l 

oe 

s 

— 

»0t 

2» 

Oi  I 

82 

s 

2 

02  1 

OE 

221 

»» 

o> 

021 

S» 

> 

ft2l 

9C 

5 

CO 

»0l 

e» 

001 

<» 

e« 

•~ 

811 

0» 

^» 

96 

2 

CO 

2il 

• 

00 1 

oe 

2 

en 

r2i 

o» 

081 

Be 

r: 

"« 

Oti 

Or 

021 

92 

CO 

« 

(ftr 

2S 

0£i 

92 

«n 

M 

ott 

8£ 

oil 

9S 

2 

- 

•  II 

82 

oil 

82 

I 

Si 

Ill 

si 

u. 
O 

jr    "«o    "•o    "x     "n    *e*     **—      o     "o*    °oo     "r- 
3UniVU3dW3X   XI3HN3UHVJ 

2 

Z 

2 

i 

PROPHYLAXIS  ^75 

typhoid  meningitis,  both  of  which  recovered.  The  symptoms  of  meningitis 
in  both  cases  developed  hite  in  the  disease,  and  typhoid  bacilli  were  ob- 
tained in  pure  culture  from  the  cerebrospinal  fluid. 

Prognosis. — The  prognosis  of  typhoid  fever  in  children  is  much  better 
than  it  is  in  adults.  In  100  cases  Blackader  had  only  one  death.  Crozer 
Griffith  reported  a  mortality  of  3  per  cent.  These  estimates,  however,  are 
much  below  the  average  mortality,  which  ranges  in  the  neighborhood  of 
6  per  cent.  In  very  young  infants  the  mortality  is  great,  from  20  to  40  per 
cent. ;  between  two  and  ten  it  is  low ;  in  children  over  ten  it  gradually 
increases. 

Differential  Diagnosis. — Paratyphoid  fever  very  closely  resembles  mild 
typhoid  fever,  but  from  the  standpoint  of  therapy  there  is  no  reason  for 
attempting  a  differential  diagnosis.  In  paratyphoid  the  Widal  reaction 
is  negative,  but  an  agglutination  reaction  may  be  obtained  by  using  para- 
typhoid cultures.  Acute  miliary  tuberculosis  is  the  disease  most  commonly 
mistaken  for  typhoid  fever.  It  produces  in  the  child  a  clinical  picture 
closely  resembling  adult  typhoid.  In  these  cases,  however,  the  absence  of 
Widal  reaction,  the  previous  history  of  the  child,  the  presence  of  other 
signs  or  symptoms  of  tuberculosis,  the  great  irregularity  of  the  temperature 
curve,  the  absence  of  rose-spots,  the  presence  of  leukocytosis  and  the  pos- 
sible finding  of  tubercles  in  the  choroid  should  suffice  to  make  the  diag- 
nosis. If  perchance  doubt  still  exists,  the  diagnosis  will  be  made  later  by 
the  long-continued  fever  and  the  complicating  tuberculous  meningitis  or 
tuberculous  bronchopneumonia.  Intestinal  grippe  may  present  a  clinical 
picture  which  suggests  typhoid  fever,  but  the  accompanying  catarrhal 
symptoms  with  an  absence  of  rose-spots,  Widal  reaction,  diazo  reaction  and 
typical  temperature  curve  should  suffice  to  make  the  diagnosis. 

Prophylaxis. — The  most  important  measure  in  prophylaxis  is  to  use 
only  uncontaminated  water  for  drinking  purposes,  and  the  best  safeguard 
in  this  direction  is  to  be  found  in  drinking  boiled  water.  This  precaution 
is  necessary  in  most  of  our  large  cities,  since  the  filtering  systems  in  vogue 
are  not  an  absolute  protection  against  this  disease.  In  country  districts, 
when  typhoid  fever  is  epidemic,  all  well  and  spring  water  should  be  care- 
fully avoided  or  should  be  boiled  before  using.  As  milk  is  also  a  source 
of  danger,  it  is  on  the  whole  safest  to  use  only  boiled  or  "clean"  raw  milk ; 
this  is  especially  advisable  during  epidemics  of  typhoid  fever.  Oysters, 
known  to  come  from  beds  contaminated  with  sewage,  should  be  avoided. 
Vegetables  and  fruit,  to  be  eaten  raw,  should  be  washed  with  boiled  water. 
The  feces  and  urine  of  typhoid  fever  patients  should  be  received  in  a  1 
to  20  carbolic  acid  or  a  1  to  1,000  bichlorid  solution.  All  bed  and  per- 
sonal clothing  of  the  typhoid  fever  patient  should  be  soaked  in  the  same 
carbolic  acid  solution  for  one  or  two  hours  and  then  boiled.  The  body  of 
the  patient  should  be  cleansed  following  evacuation  of  the  bowels.  The 
nurse  should  exercise  the  greatest  care  in  handling  the  excreta  and  cloth- 
ing of  the  patient,  and  should,  after  such  handling,  carefully  disinfect  her 
hands,  for  only  in  this  way  may  she  be  sure  that  she  will  not  infect  herself 


276  TYPHOID  FEVER 

directly,  or  contaminate  her  food  supply  with  the  typhoid  bacilli  clinging 
to  her  hands.  While  it  is  not  necessary  to  isolate  or  quarantine  typhoid 
fever  patients,  it  should  be  remembered  that  the  interests  of  the  patient 
and  the  safety  of  the  household  are  best  served  by  preventing  all  unnec- 
essary contact  between  the  sick  and  the  well. 

Nursing  mothers  with  typhoid  should  wean  their  babies,  not  only  for 
the  protection  of  the  infant,  but  for  the  welfare  of  the  mother. 

Anti-typhoid  inoculations  with  sterile  typhoid  cultures,  as  practiced  by 
A.  E.  Wright  in  India,  produce  an  increased  temporary  resistance  to  the 
typhoid  infection.  This  prophylactic  measure,  however,  is  hardly  justi- 
fiable except  for  the  protection  of  hospital  attendants  or  large  bodies  of 
people  who  are  especially  predisposed  to  this  disease  by  camp  life. 

Treatment.— Tvphoid  fever  is  a  self-limited  disease  for  which  we  have 
no  specific  medication.  It  can,  however,  be  materially  influenced  in  its 
severity  and  shortened  in  its  course  by  careful  attention  to  hygienic  details 
and  to  proper  dietetic  and  medical  treatment.  The  patient  should  be  put 
to  bed,  and  remain  there  for  at  least  one  week  after  all  acute  symptoms 
have  disappeared.  The  room  which  he  occupies  should  be  large  and  well 
ventilated.  A  comfortable  bed  should  be  provided  with  a  smooth  hair 
mattress  resting  on  box  springs,  and  a  rubber  cloth  should  protect  the  mat- 
tress underneath  the  sheet.  Good  nursing  is  all-important;  the  patient 
should  always  be  under  the  watchful  eye  of  a  competent  observer.  In  older 
children  the  bed-pan  and  urinal  should  be  used  and  it  should  be  the  ob- 
ject of  the  nurse  to  tactfully  keep  the  patient  as  quiet  as  possible,  allow- 
ing him  to  do  nothing  for  himself  that  can  be  done  by  others.  With  a 
young  child  it  may  be  necessary  to  lift  him  out  of  bed  and  hold  him  tem- 
porarily in  arms;  this  may  relieve  the  nervous  irritability  and  fretfulness. 
The  hips  and  back  of  the  patient  should  be  rubbed  once  or  twice  a  day 
with  alcohol  and  the  position  of  the  body  changed  from  time  to  time;  this 
is  necessary  in  severe  cases  to  prevent  the  formation  of  bed  sores.  Care- 
ful records  of  pulse,  temperature  and  respiration  should  be  taken  at  reg- 
ular intervals  and  the  nurse  instructed  as  to  the  warning  symptoms  of 
hemorrhage  and  perforation,  so  that  she  may  summon  medical  assistance 
at  once  if  these  symptoms  occur.  The  mouth,  throughout  the  disease, 
should  be  carefully  cleansed  three  times  a  day  with  a  mild  alkaline  anti- 
septic; this  will  greatly  diminish  the  danger  of  parotid  infection  and 
prevent  the  dry  and  fissured  tongue  which  comes  from  mouth  contami- 
nation. 

Routine  Treatment. — Diet. — The  dietetic  treatment  is  all-important. 
In  the  child,  even  more  than  in  the  adult,  milk  is  the  most  important 
article  of  diet.  In  young  children,  however,  it  is  advisable  to  combine  it 
with  a  cereal  gruel.  If  diarrhea  occurs  with  curds  in  the  stool,  it  is 
advisable  to  substitute  skimmed  milk  for  whole  milk;  if  this  does  n^t 
correct  the  trouble  the  skimmed  milk  or  the  whole  milk  may  be  peptonized 
and  combined  with  barley  water.  It  is  of  the  greatest  importance  that 
the  intestinal  discharges  of  the  child  be  inspected  from  day  to  day,  for  the 


TREATMENT  277 

purpose  of  determining  whether  the  food  is  undergoing  abnormal  fermenta- 
tion and  thereby  adding  the  symptoms  of  intestinal  toxemia  to  tliose  of 
typhoid;  in  this  event  the  dietetic  measures  previously  outlined  for  the 
treatment  of  acute  diarrheal  diseases  are  applicable.  The  "buttermilk 
mixture,"  thick  cereal  decoctions,  fresh  meat  juice  and  some  of  the  pro- 
prietary meat  preparations,  such  as  liquid  peptonoids,  panopeptin,  and 
Valentine's  meat  juice,  are  of  value  in  many  of  these  cases.  The  pro- 
prietary milk  foods,  such  as  malted  milk  and  Nestle's  food,  may  be  used 
and  flavored  with  cocoa  to  make  them  more  palatable.  It  is  most  impor- 
tant that  the  child  should  not  be  fed  too  frequently  or  too  much,  but,  if 
possible,  a  sufficient  number  of  calories  should  be  given  to  satisfy  nutri- 
tional demands  and  prevent  great  loss  of  weight.  Where  the  digestive 
capacity  of  the  child,  however,  is  such  that  it  must  necessarily  be  greatly 
underfed,  then  alcohol  should  be  used  not  as  a  stimulant  but  as  a  food  to 
make  up  the  deficiency  in  calories.  Alcohol  may  be  given  in  the  form  of 
the  proprietary  meat  preparations  above  mentioned  or  good  whiskey  and 
brandy  well  diluted  may  be  used.  For  a  child  six  years  of  age,  two  tea- 
spoonfuls  of  whiskey  as  a  toddy  or  combined  with  carbonated  water  may 
be  given  every  four  hours;  alcohol  given  under  these  conditions  serves  as 
a  fuel  for  the  cells  of  the  body  and  prevents  nitrogenous  waste.  As  a  part 
of  the  routine  treatment  the  patient  should  be  given  plenty  of  water;  this 
flushes  the  excretory  organs  and  diminishes  the  toxemia.  During  conva- 
lescence the  same  diet  upon  which  the  child  has  gone  successfully  through 
its  illness  should  be  continued  for  one  week  after  the  temperature  has 
reached  normal,  then  gradually  soft-boiled  eggs,  milk-toast,  scraped  meat- 
ball, orange  juice,  bread,  and  other  foods  may  be  added. 

At  the  onset  the  patient  should  have  a  dose  of  calomel,  followed  by 
castor-oil  or  a  saline  cathartic.  Dilute  hydrochloric  acid  to  older  children 
and  guaiacol  carbonate  and  salol  to  young  children  may  then  be  given  as  a 
matter  of  routine  treatment. 

The  hath  is  an  important  part  of  the  routine  treatment;  it  reduces  the 
fever,  makes  the  patient  more  comfortable,  quiets  his  nervous  system,  pro- 
duces sleep,  and  acts  as  a  general  tonic.  The  routine  treatment  of  tub- 
bathing  by  Brand's  method,  which  is  of  great  value  in  the  treatment  of 
adult  typhoid,  is  neither  advisable  nor  necessary  in  the  treatment  of  this 
disease  in  children;  the  shock  and  excitement  produced  by  the  cold  bath 
more  than  counteracts  its  good  effects.  In  ordinary  cases  a  tepid  bath 
with  water  containing  alcohol,  or  the  fan-bath,  should  be  given  three  times  a 
day.  If  the  fever  be  high  and  the  nervous  symptoms  marked,  this  bath,  pro- 
longed for  ten  minutes,  may  be  given  with  cool  water  and  an  ice-bag  applied 
to  the  head.  Where  the  nervous  symptoms  and  high  temperature  are  still 
more  pronounced  the  patient  may  be  given  a  cold  pack  by  wrapping  him  in 
sheets  wrung  out  of  cold  water  and  then  covering  him  with  a  blanket;  dur- 
in'g  this  process  the  arms  and  legs'should  be  rubbed  to  promote  circulation. 
The  character  of  the  hydrotherapeutic  measures  used  will  largely  depend 
upon  the  severity  of  the  symptoms  and  the  age  and  temperament  of  the 


278  TYPHOID    FEVEK 

child.  Whatever  measures  are  adopted  should  favorably  influence  the  symp- 
toms and  make  the  patient  more  comfortable. 

Symptomatic  Treatment. — It  is  rarely  necessary  to  use  energetic 
measures  for  the  control  of  the  fever;  the  hydrotherapeutic  measures  above 
given  usually  answer  every  purpose.  Beating  down  the  temperature  does 
not  shorten  or  favorably  influence  the  disease,  and  medical  antipyretics  are 
therefore  not  indicated.  The  coal-tar  products,  such  as  phenacetin  and 
antipyrin,  will  do  more  harm  than  good  if  given  for  any  length  of  time. 

The  nervous  symptoms  can  usually  be  controlled  by  hydrotherapy  and 
an  ice-bag  to  the  head.  The  bromides  may  be  of  value  in  some  cases. 
Opium  in  rare  instances  may  be  indicated  in  older  children,  but  should  be 
avoided  if  possible,  as  it  aggravates  the  constipation  and  increases  the  in- 
testinal toxemia.  Intestinal  pain,  when  severe  enough  to  demand  treat- 
ment, is  best  relieved  by  paregoric. 

Constipation,  which  is  the  rule  in  younger  children,  can  usually  be  over- 
come by  enemata  and  suppositories;  if,  however,  these  do  not  suffice,  laxa- 
tives should  be  used,  such  as  milk  of  magnesia,  castor-oil,  and  aromatic 
cascara.  Much  harm  may  be  done  by  the  constipation  and  resulting  in- 
testinal toxemia,  and  the  unfounded  dread  of  laxatives  not  infrequently 
prolongs  the  disease  many  weeks. 

It  should  be  remembered  that  the  diarrhea  of  typhoid  fever  is  for  the 
most  part  salutary,  and  is  nature's  effort  at  elimination;  if  this  symptom 
be  not  excessive  it  requires  no  treatment.  From  two  to  four  loose  stools  in 
twenty-four  hours  is  better  than  constipation ;  excessive  diarrhea,  however, 
should  be  controlled  by  subnitrate  of  bismuth  in  5-  to  10-grain  doses,  put 
up  in  simple  chalk  mixture.  In  aggravated  cases  it  may  be  necessary  to 
give  paregoric,  care,  however,  being  taken  that  the  diarrhea  be  not  too 
suddenly  controlled  or  converted  into  constipation.  In  every  case  of  ex- 
cessive diarrhea  the  diet  should  be  modified  to  suit  the  conditions;  it  may 
be  necessary  to  discontinue  milk  for  a  few  days  and  substitute  for  it  broth, 
albumin  water,  meat  juice,  cereal  decoctions,  or  whiskey.  When  the  milk 
is  resumed  it  may  be  skimmed,  peptonized,  or  diluted  with  a  cereal  decoc- 
tion as  the  exigencies  of  the  case  demand.  In  short,  a  typhoid  fever  case 
with  an  aggravated  diarrhea  is  to  be  fed  as  though  we  were  dealing  with  an 
acute  enteritis.  If  marked  meteorism  be  present  a  soft  rubber  catheter 
introduced  high  into  the  colon,  as  recommended  by  Forchheimer,  may  be 
of  value  in  carrying  off  gas  and  relieving  the  abdominal  distention. 

Intestinal  hemorrhage  requires  the  same  treatment  as  in  the  adult,  viz., 
absolute  quiet,  the  patient  doing  nothing  that  can  be  done  for  him  by 
others;  temporary  abstinence  from  food,  water  and  ice  being  allowed;  a 
hypodermic  injection  of  morphin,  1/30  of  a  grain  for  a  child  six  years  of 
age,  to  be  repeated  in  six  or  eight  hours,  and  the  application  of  cold  to  the 
abdomen  by  ice-bags,  a  layer  of  flannel  intervening.  If  the  hemorrhage  be 
great  and  collapse  threatens,  the  patient  should,  be  stimulated  by  hypo- 
dermoclysis  of  normal  salt  solution  and  by  the  hypodermic  use  of  tincture 
of  strophanthus,  3  or  3  drops,  well  diluted,  for  a  child  six  years  of  age. 


ETIOLOGY  279 

Intestinal  perforation  demands  immediate  surgical  interference;  when 
the  physician  suspects  this  condition  surgical  advice  should  be  sought. 

May  typhoid  fever  patients  be  sent  home  without  additional  risk? 
— This  is  often  a  question  of  the  greatest  importance  and  one  that  the 
physician  is  called  upon  to  decide.  In  a  typhoid  fever  epidemic  which  I 
studied  in  northern  Michigan  some  ten  or  fifteen  patients  were  sent  to 
their  homes  in  the  first  and  second  weeks  of  the  disease.  Some  of  these 
had  a  fourteen  hours'  railroad  journey,  others  a  twenty-four  hours'  journey 
by  boat,  and  all  of  them  reached  their  homes  in  safety  and  made  satisfac- 
tory recoveries.  One  of  these  patients  had  a  temperature  of  over  105°  F. 
when  she  was  carried  to  the  train.  .With  these  particular  cases  it  was  a 
question  of  remaining  in  uncomfortable  summer  cottages  through  a  long 
illness  or  of  being  treated  at  home  under  most  satisfactory  conditions. 
Under  such  circumstances  there  should  be  no  hesitation  in  sending  typhoid 
fever  patients  to  their  homes  during  the  first  week  of  the  disease;  this  is 
especially  true  of  children.  Other  things  being  equal,  however,  typhoid 
fever  patients  should  be  treated  where  they  are  taken  ill,  and  above  all 
should  not  be  moved  in  the  later  stages  of  the  disease.  There  is  more 
danger  in  traveling  during  early  convalescence  than  during  the  first  week 
of  the  disease. 


CHAPTEK   XXXV 

MALAEIA 

Malaria  is  an  acute  infectious  disease  caused  by  the  plasmodium  ma- 
lariae;  it  is  characterized  by  more  or  less  regular  recurring  intermittent  or 
remittent  symptoms,  the  most  pronounced  of  which  is  fever. 

Etiology.- — The  sole  cause  is  the  plasmodium  malariae,  a  hemacytozoon 
discovered  by  Laveran  in  1880.  This  parasite  is  found  in  three  forms,  the 
tertian,  the  quartan,  and  the  estivoautumnal ;  of  these  the  tertian  is  by  far 
the  most  common  and  is  present  in  the  great  majority  of  the  cases.  On 
first  entering  the  red  blood  corpuscle  it  appears  as  a  small  mass  of  non- 
pigmented  protoplasm.  As  it  gradually  increases  in  size  it  becomes  more 
and  more  pigmented,  and  the  hemoglobin  is  gradually  destroyed  until  the 
corpuscle  finally  appears,  much  paler  than  normal,  inclosing  a  pigmented 
mass  almost  filling  the  cell.  This  mass  splits  into  segments  which  are  dis- 
charged into  the  blood  during  the  chill  stage ;  they  subsequently  enter  other 
red  corpuscles,  where  the  same  process  is  repeated.  The  full  cycle  of  its 
development  in  the  body  is  forty-eight  hours,  and  this  cycle  represents  the 
clinical  manifestations  of  a  malarial  paroxysm,  including  the  intervening 
quiescent  period.  In  children,  more  commonly  than  in  adults,  there  is  a 
double  infection  by  two  gets  of  tertian  parasites  which  mature  on  alternate 
days,  thereby  producing  a  paroxysm  of  acute  symptoms  every  day.  The 
two  sets  of  parasites  may  or  may  not  mature  at  the  same  hour  on  alter- 


280  MALARIA 

nate  days,  so  that  in  these  cases  of  double  infection  the  acute  symptoms, 
while  they  recur  at  practically  the  same  hour  every  third  day,  may  vary  as 
to  the  time  of  the  beginning  of  the  paroxysms  on  alternate  days.  Another 
point  of  clinical  importance  is  that  the  paroxysms  caused  by  the  two  sets  of 
parasites  may  markedly  vary  in  their  intensity ;  a  severe  paroxysm  occurring 
every  third  day  and  a  mild  paroxysm  on  the  intervening  days.  The  quartan 
parasite,  which  requires  seventy-two  hours  for  its  cycle  of  development, 
produces  acute  clinical  manifestations  every  fourth  day,  and  the  estivoau- 
tumnal  parasite,  which  is  the  cause  of  the  irregular  and  more  severe  forms 
of  malaria,  may  complete  its  cycle  within  twenty-four  hours.  This  para- 
site is  commonly  found  in  the  remittent  malarial  fevers,  and  while  nothing 
like  so  common  as  the  tertian  parasite,  is  not  infrequently  found  in  the 
United  States.  The  quartan  parasite  is  rare.  Malarial  parasites  as  they 
occur  in  children  present  no  peculiarities  from  the  forms  found  in  the 
adult.  A  detailed  description  of  these  various  forms  may  be  found  in  the 
text-books  on  practice. 

Infection. — The  anopheles,  a  genus  of  mosquito,  is  the  all-important 
agent  by  which  the  disease  is  transferred  from  man  to  man,  and  so  far  as 
we  are  aware  this  is  the  only  means  by  which  the  disease  is  spread.  The 
mosquito  becomes  infected  with  the  malarial  parasite  by  sucking  the  blood 
of  a  malarial  patient ;  it  acts  as  the  intermediate  host  for  this  parasite  and 
in  its  body  the  life  cycle  of  the  plasmodium  is  completed.  This  requires 
about  a  week,  and  then  large  numbers  of  malarial  sporozoids  are  excreted 
by  the  salivary  glands  and  are  transferred  to  man  by  the  biting  of  the  mos- 
quito. In  the  body  of  the  individual  thus  inoculated  by  the  infected  mos- 
quito the  parasites  rapidly  multiply,  as  previously  described,  until  they 
are  present  in  sufficient  numbers  to  produce  clinical  symptoms.  The  time 
thus  occupied  in  the  body  of  their  host  before  clinical  symptoms  are  pro- 
duced is  on  the  average  fourteen  days,  and  this  represents  the  stage  of 
incubation. 

In  the  middle  and  northern  portions  of  the  United  States  malaria  is 
more  prevalent  in  the  late  summer  and  early  fall.  It  is  more  commonly 
seen  in  the  southern  and  Atlantic  coast  states  than  in  the  north  and  west. 
It  is  more  prevalent  in  the  neighborhood  of  stagnant  water  and  there  is 
greater  liability  to  contract  it  after  sunset  than  during  the  day.  All  of 
these  facts  may  be  explained  by  the  habits  and  habitats  of  the  mosquito. 

latency  of  Malaria. — This  is  one  of  the  diseases  characterized  by  latent 
stages ;  the  parasite,  once  it  has  gained  access  to  the  human  body,  may  re- 
main dormant  or  latent  for  long  periods  of  time.  The  acute  symptoms  of 
the  disease  having  been  temporarily  controlled  and  the  patient  liaving  ap- 
parently made  a  satisfactory  convalescence,  a  second  attack  of  acute  malaria 
may  occur  -without  a  new  infection.  Relapses  more  commonly  occur  when 
the  individual  harboring  these  latent  parasites  has  a  lowered  resistance  oc- 
casioned by  disease,  or  other  causes  which  diminish  the  vitality  and  pro- 
duce malnutrition,  thus  provoking  second  attacks  of  malaria  even  long 
after  the  patient  has  recovered  from  the  primary  attack. 


SYMPTOMATOLOGY  281 

Immunity. — One  attack  of  malaria  not  only  does  not  confer  immunity, 
but  predisposes  the  child  to  second  attacks.  Natural  immunity  is  very 
rare.  The  negro,  however,  appears  to  be  slightly  less  susceptible  than  the 
Caucasian.  No  age  is  immune.  Infants,  children,  and  adults  are  alike 
puscej)tible  to  this  disease.  It  may  even  occur  in  utero  and  is  ])erhaps  not 
infrequently  transmitted  in  this  way  from  the  mother  to  the  child.  Below 
is  given  the  temperature  chart  of  a  case  of  congenital  malaria.  The  mother, 
while  pregnant  with  this  infant,  visited  a  malarious  country  and  there  con- 
tracted the  disease.  She  suifered  severely  from  tertian  malaria  during  the 
last  months  of  her  pregnancy.  The  infant  was  born  and  lived  in  a  section 
of  country  absolutely  free  from  malaria,  and  when  sixteen  months  of  age 
it  became  violently  ill  with  a  gastroenteric  infection.  In  the  convalescence 
from  this  attack  it  developed  a  severe  form  of  tertian  malaria,  the  typical 
parasites  appeared  in  the  blood  and  the  disease  was  controlled  by  quinin 
administered  hypodermically.  Crandall  reported  a  case  occurring  eighteen 
hours  after  birth.  Infant  had  distinct  malarial  parox3'sms  and  the  blood 
of  both  the  mother  and  child  contained  malarial  parasites.  The  general 
consensus  of  opinion  is  that  infants  are  perhaps  more  susceptible  but  less 
exposed  to  inoculation  by  the  malarial  mosquito  than  adults.  If  fewer 
cases,  therefore,  occur  among  infants  it  is  rather  due  to  their  protection 
from  the  mosquito  than  to  the  lack  of  their  susceptibility.  Loffler  says 
that,  "children  are  exclusively  the  carriers  of  the  parasites  in  many  dis- 
tricts in  which  malaria  is  endemic  and  that  only  the  examination  of  the 
children  will  determine  whether  endemic  malaria  is  present  in  a  locality." 
This,  he  says,  is  an  observation  of  Koch  of  great  importance  in  the  prophy- 
laxis of  the  disease. 

Symptomatology. — In  children  over  eight  or  ten  years  of  age  the  symp- 
tomatology is  practically  the  same  as  that  in  adults.  The  periodicity  of 
the  symptom  group  is  its  chief  characteristic.  In  the  common  form  of 
malaria  produced  by  the  tertian  parasite  the  paroxysm  is  usually  an- 
nounced by  a  general  feeling  of  discomfort,  associated  with  headache,  chilli- 
ness, and  sometimes  a  pronounced  rigor,  with  nausea  and  vomiting.  With 
the  onset  of  these  symptoms  the  hands  and  feet  are  cold,  the  lips  blue,  and 
hot  water  bottles  and  extra  bed  covering  are  utilized  to  make  the  patient 
more  comfortable.  The  temperature  rises  rapidly  and  may  reach  104°  or 
105°  F.  within  two  hours;  the  headache  grows  worse,  the  body  chill  grad- 
ually disappears,  the  patient  becomes  hot  and  thirsty,  asks  for  water,  and 
throws  off  the  heavy  covering  that  has  been  used  in  the  stage  of  rigor. 
Soon  after  the  temperature  reaches  its  height  it  begins  to  fall,  but  not  quite 
as  rapidly  as  it  rose.  It  may  reach  normal,  or  even  below,  in  the  course 
of  a  few  hours,  so  that  the  duration  of  the  fever  may  vary  in  individual 
cases  from  one  to  twelve  hours ;  it  commonly  runs  its  course  in  four  or  five 
hours.  With  the  fall  in  the  temperature  a  profuse  perspiration  may  occur ; 
this  symptom,  however,  is  not  so  pronounced  in  the  child  as  in  the  adult. 
As  the  temperature  reaches  normal  the  headache  and  other  disagreeable 
symptoms  disappear  and  the  patient  is  in  a  condition  of  comparative  com- 


282 


MALARIA 


fort.     The  contrast  between  the  great  suffering  which  occurs  during  the 
height  of  the  malarial   paroxvtJin   and   the   freedom   from   uncomfortable 


s 

m 

i 

s 
-« 
5 

c 

s 

o 

11 

2o 

S 

FAHRENHEIT    TEMPERATURE 

DETA1L5                                                                                                                                                       ClINICAt 
OFTBE»Tie>T                                                                                                              .    «E«OH>NDA 

1    2     1    g         g         i         2        S         S,        2    1    S         sis 

i 

n 

19 

ll« 

1 

1 1 

• 

&    P.M- 

r~ 



a  »-•• 

« 

la 
la 

/ 

^,. 

1 

.1    A    U 

"1 

:C^ 

:  P.M. 

n 

n 

a* 
tt« 

9 

< 

— 



5    P.«l 

^ 

"*"■ 

— ^. 

*«.i. 

a 

ta 

— 

~3 

a  .\  u 

-—i-r- 

-^ 

J  P.M. 

ji 

M 

•tt 

3 

.--tl 

1 

=*• 

5   P.>1 

^^- 

^~ 

«     ».«L 

at 

B 

in 

h- 

.1  AM 

I  P.M. 

» 

tt 

M 

•t« 
tt« 

4 

^ 

A 

5    P« 

^s::^ 

f    ..«- 

.^ 

— . 

....,__^ 

..  i  K 

■> 

— 

;  P.M. 

93 

tt 

It* 

5 

^•^ 

=» 

»  p.«i 

3  Gr   VuioiBC  H^jj^. 

/ 

" 

«  >.•• 

a 

in 

4 

'     / 

a.\  M 

3  Ut    VunMlv  Hrpo- 

.'^ 

/ 

;  P.M. 

H 

M 

•  t« 

•t« 

6 

V-^ 

5    P.M 

3Gr   guiDiocHjpo 

•— 

^'^ 

e  A. ML 

3Gi   QoiDiDeHjpa 

a 

IM 
122 

A 

' 

11  .t.M 

4 

^ 

i  P.M. 

6  Gr  faqumiiK 

S 

in 

7 

L 

__ 

■•■ — 

^ 

!    P  " 

— — : 

»s^ — 

.^ 

<   •..■ 

3  Gt   <)<iioiDe  Hipo 

a 
a 

U2 

la 

■~3» 

.1  1  M 

-i>< 

.'  P  M . 

M 

t« 

»• 

•t« 

8 

^^' 

•-■■" 



is. 

*    P  M 

4G.   yum.D.H5,« 

-^m    " 

'• 

>    •.•■ 

<  Gr    Hiimm.  Hjpi 

1^1 

•' 

■* 

11  AM 

1 

2  P.M. 

«  Gr   <Juimi«  Hjpo. 

II 

n 

't» 

9 

1 

>* 

5   P.M. 

,t 

^ 

«   «.». 

4  Gr.  Quioio.  Hjpo. 

la 

, 

il  A.M. 

s 

2  P.M. 

a 

n 
** 

■  M 
•tt 

10 

\  "s 

5    P.n. 

\ 

S 

9    »■•«- 

4  Gr.  Quinine  Hjpo. 

M 
M 

la 
■a 

1 

'V 

.1  A.M. 

^^ 

I  P.M. 

n 

t« 
t< 

•t» 
<t» 

II 

1 

\ 

S    P.«l. 

e  ..•■. 

H 

a 

la 

i  \ 

.1  A.M. 

> 

I  P.M. 

» 

M 

•tt 

/ 

• 

5    P.M. 

i 

^r' 

S    *.•• 

Qutiint  InjKtiMi 

B 

a 

m 
m 

/ 

.1  A.M. 

> 

2  P.M. 

31 

tta 

tt4 

(* 

5    P.« 

4  Gr.  Quume  H;po 

N 

; 

•   »." 

M 

W 

la 
la 

\ 

V 

.1  A.M. 

^ 

2  P.M. 

t< 
M 

tt« 

itt 

^*o 

%    P.M 

4  Gt    Quinioe  Hjljo. 

V 

( 

«    »J«. 

(JuiniD*  Inwrtioo 

;a 

> 

11  A.M. 

4Gt   VluiDlKH.,.. 

'' 

2  P.M. 

Fig.  46. — Congexital  Mal.\ri.\;  Child  One  Year  of  Age. 

symptoms  which  marks  the  interval  between  paroxysms  is  very  great.    The 
paroxysms  of  malaria  produced  by  the  tertian  parasite  commonly  occur 


SYMPTOMATOLOGY  283 

every  day,  producing  the  quotidian  rather  than  the  tertian  type  of  temper- 
ature. The  daily  paroxysms  being  due  to  a  double  infection  by  two  sets  of 
tertian  parasites  which  mature  on  alternate  days,  thus  producing  a  well- 
marked  daily  intermittent  fever.  The  maximum  temperature  being 
reached  at  the  same  hour  on  alternate  days,  but  perhaps  varying  from  this 
hour  somewhat  on  the  intervening  days.  If  the  child  be  infected  by  only 
one  set  of  tertian  parasites  a  typical  tertian  intermittent  fever  is  present; 
the  paroxysm  of  fever,  with  its  accompanying  symptoms,  occurring  every 
third  day  and  reaching  its  maximum  about  the  same  hour;  on  the  inter- 
vening day  the  child  is  comparatively  comfortable.  The  quartan  parasite, 
which  is  rarely  seen  in  the  United  States,  produces  an  intermittent  fever, 
the  paroxysms  of  which  occur  about  the  same  hour  every  fourth  day.  In 
the  two  intervening  days  the  patient  is  comparatively  comfortable.  The 
estivoautumnal  parasite  produces  an  irregular  type  of  fever  commonly  re- 
mittent or  very  irregularly  intermittent.  In  this  type  of  malaria  great 
variations  in  the  temperature  may  occur  from  hour  to  hour  and  only  fre- 
quent temperature  records  can  keep  track  of  the  excursions  which  the  tem- 
perature may  make,  but  on  the  whole,  in  this  form  of  malaria,  the  tem- 
perature may  be  considered  as  belonging  to  the  continuous  remittent  type 
rather  than  to  the  intermittent  type. 

Spleen. — In  all  forms  of  malaria  the  spleen  is  notably  enlarged  and  can 
easily  be  palpated.  In  the  typically  remittent  tertian  form  it  may  increase 
in  size  during  the  paroxysms.  In  chronic  forms  of  malaria  the  enlarge- 
ment of  the  spleen  is  very  great  and  is  an  important  diagnostic  feature. 
The  liver  is  also  commonly  enlarged. 

Anemia. — Acute  malaria  produces  a  well-marked  anemia  which  in  ag- 
gravated and  chronic  cases  may  cause  the  characteristic  malarial  cachexia 
in  which  the  skin  has  a  pale  yellow  color.  The  enormously  enlarged  spleen 
which  is  associated  with  this  cachectic  condition  may  suggest  the  possibil- 
ity of  some  form  of  severe  primary  anemia.  A  blood  examination  of  these 
cases,  however,  shows  no  leukocytosis  and  reveals  the  existence  of  a  pro- 
found secondary  anemia,  which  is  marked  by  a  great  liiminution  of  both 
red  blood  corpuscles  and  hemoglobin.  This  secondary  anemia  sometimes 
resembles  the  chlorotic  type. 

Intermittent  neuralgia  is  one  of  the  common  manifestations  of  sub- 
acute or  chronic  malaria  in  older  children.  The  supraorbital  nerve  is  a 
favorite  site  for  this  pain,  but  almost  any  nerve  in  the  body  may  be  af- 
fected. The  paroxysm  recurs  at  about  the  same  hour  every  day  or  every 
second  day,  but  is  not  necessarily  accompanied  by  fever.  The  periodicity, 
however,  of  a  neuralgia  by  no  means  classes  it  as  malarial,  since  neuralgia 
from  other  causes  may  return  at  more  or  less  regular  intervals.  Intermit- 
tent spasmodic  torticollis  occurring  at  the  same  time  every  day,  or  every 
second  day,  is  a  malarial  manifestation  rather  more  common  in  the  child 
than  it  is  in  the  adult. 

Peculiarities  of  Malaria  in  the  Infant. — From  the  above  clinical  syn- 
drome of  malaria,  as  it  occurs  in  the  child,  there  may  be  variations  in  in- 


284  MALARIA 

fancy.  At  this  period  the  chill  is  absent  and  for  it  a  condition  of  drowsi- 
ness, cold  hands  and  feet,  with  marked  prostration,  may  be  substituted. 
Convulsions  occasionally  occur.  Vomiting  very  commonly  marks  the  onset 
of  the  paroxysm  and  nausea  may  continue  until  the  fever  begins  to  subside. 
The  onset  of  acute  symptoms  is  usually  more  abrupt  in  the  infant  and  the 
paroxysm  is  sometimes  associated  with  an  acute  pulmonary  congestion 
which  may  suggest  the  onset  of  pneumonia. 

Diagnosis. — The  diagnosis  is  positively  made  by  finding  in  the  blood 
the  Plasmodium  malaria? ;  this  is  not  always  a  simple  matter.  A  number  of 
blood  examinations  are  not  infrequently  required  before  the  plasmodium  is 
discovered.  The  blood  for  these ,  examinations  should  be  obtained  shortly 
before  the  onset  of  the  malarial  paroxysm,  when  the  red  blood  corpuscles 
contain  the  pigmented  parasite.  This  examination  should  also  be  made 
before  quinin  is  given. 

Pronounced  simple  anemia  with  an  enlarged  spleen  and  regularly  re- 
curring paroxysms  of  fever  and  no  leukocytosis  suggests  the  probability  of 
malaria.  If  under  these  conditions  an  examination  for  the  plasmodium  be 
not  practicable  the  diagnosis  may  be  confirmed  by  the  specific  action  which 
quinin  has  on  these  symptoms.  In  tuberculosis,  pyemia,  septicemia,  pye- 
litis, and  other  conditions  we  may  have  intermittent  paroxysms  of  chills 
and  fever  closely  resembling  irregular  forms  of  malaria.  But  in  these 
conditions  the  plasmodium  is  not  found  in  the  blood  and  the  symptoms  are 
not  specifically  influenced  by  the  giving  of  quinin.  Probably  the  most 
common  source  of  diagnostic  error  lies  in  the  remittent  forms  of  malaria, 
which  may  be  mistaken  for  typhoid  or  some  other  continuous  fever. 

Treatment. — Prophylaxis  may  best  be  accomplished:  First,  by  the 
destruction  of  the  malarial  mosquito  (anopheles).  This  may  be  accom- 
plished by  fumigating  infected  houses  with  sulphur;  destroying  the  breed- 
ing places  of  the  mosquitoes  by  draining  stagnant  pools  and  killing  the 
young  anopheles  by  pouring  crude  petroleum  over  all  stagnant  water  that 
cannot  be  drained.  Second,  by  preventing  man  from  being  bitten  by  the 
infected  mosquito.  This  may  be  done  by  the  use  of  house  screens  and 
mosquito  netting  to  cover  the  beds.  Third,  by  the  prompt  and  effective 
treatment  of  all  malarial  cases  in  the  neighborhood  so  as  to  prevent  the 
anopheles  becoming  infected.  Fourth,  by  good  food  and  proper  hygiene 
for  increasing  the  resisting  power  of  the  individual. 

Medical  Treatment. — Quinin  is  a  specific  for  malaria.  When  it 
reaches  the  blood  it  rapidly  destroys  the  malarial  parasites  and  quickly 
terminates  the  symptoms  of  this  disease. 

Method  of  Administration  of  Quinin. — In  older  children  the  sulphate 
may  be  given  in  capsules.  Pills  are  not  to  be  used,  since  they  may  pass 
through  the  intestinal  canal  without  being  dissolved.  In  younger  children 
the  bimuriate  or  bisulphate  of  quinin  is  preferable ;  the  solubility  of  these 
preparations  promotes  their  absorption  and  thereby  adds  greatly  to  their 
efficacy.  I  have  seen  young  children  suffering  from  malaria  who  refused 
to  yield  to  the  sulphate  and  the  various  so-called  tasteless  preparations  of 


TEEATMENT  385 

quinin,  wlio  promptly  responded  to  the  bisnlphate  given  in  solution  or  to 
hypodermic  injections  of  quinin  urea  hydrochlorate.  The  following  pre- 
scriptions are  recommended : 

JJ      Quinin  bimuriati    . . . .   5   ss  R      Quinin  bisulphat    ....  3  ss 

Sodii  chloridi    grg    y  Acidi    tartaric    grs.  xv 

AqusB  destilatse    |  ii  Aquae   destilatse    |  ii 

J^     Quinin  urea  hydrochlor.  3  gg 
Aquaj  destilatae    |  ii 

The  great  difficulty  that  attaches  to  the  administration  of  quinin  in 
children  is  its  very  disagreeable  taste.  Where  it  is  possible  it  is  better  to 
administer  the  quinin  in  aqueous  solution,  as  in  this  form  there  is  less  pos- 
sibility that  it  may  disturb  the  stomach  and  produce  vomiting.  With  young 
children  a  dose  of  the  above  solution  may  be  mixed  at  the  time  of  giving 
with  a  small  quantity  of  syrup  of  licorice  or  elixir  of  yerba  santa  to  cover 
the  disagreeable  taste  of  the  quinin.  Euquinin  in  double  the  dosage  of 
other  quinin  preparations  may  be  given  to  infants,  as  it  is  comparatively 
tasteless  and  does  not  irritate  the  stomach.  The  insoluble  tannate  of 
quinin  put  up  in  the  form  of  quinin  chocolates  is  of  little  or  no  value.  It 
is  always  desirable  to  administer  quinin  by  the  mouth  where  this  is  possible ; 
but  an  irritable  stomach  or  failure  in  assimilation  may  make  it  necessary  to 
give  quinin  in  some  other  way.  Under  such  conditions  it  should  be  used 
hypodermically,  and  the  above  solutions  of  bimuriate,  bisulphate,  and  quinin 
urea  hydrochlorate,  when  properly  sterilized,  may  be  administered  in  this 
manner.  With  the  latter  preparation  I  have  had  considerable  experience. 
All  of  these  are  more  or  less  irritating  when  given  hypodermically,  but  the 
urea  hydrochlorate  is  perhaps  less  so.  Each  injection  is  followed  by  a 
well-marked  induration  of  the  subcutaneous  tissues  which  subsides  in  a 
few  days.  The  hypodermic  treatment  of  malaria  does  not,  as  a  rule,  have 
to  be  continued  longer  than  three  days.  By  this  time  the  malarial  par- 
oxysms will  have  come  under  control,  the  nausea  and  vomiting  will  have 
disappeared,  and  quinin  may  again  be  administered  by  the  mouth.  It  may 
also  be  administered  by  rectum;  for  this  purpose  the  above  solutions  are 
available.  They  should,  however,  be  largely  diluted  six  or  eight  times  with 
a  dextrinized  cereal  decoction  or  with  a  thin  starch  water.  There  is  no 
question  but  that  absorption  may  take  place  when  the  drug  is  given  in  this 
manner,  but  the  amount  of  absorption  is  uncertain  and  the  method  is  far 
from  reliable.  I  have  little  faith  in  suppositories  of  quinin  and  believe 
that  they  are  comparatively  useless.  Quinin  cannot  be  given  by  inunction ; 
the  drug  is  not  absorbed  through  the  skin.  I  have  demonstrated  this  fact 
to  my  own  satisfaction  by  careful  experimentation. 

Dose  of  Quinin. — At  one  year  of  age,  two  grains  every  four  hours;  at 
two  years  of  age,  four  grains ;  at  four  years  of  age,  six  grains ;  at  six  years 
of  age,  eight  grains;  increasing  one  grain  for  every  year  of  life  thereafter. 
For  hypodermic  use  the  dose  should  be  one-half,  and  for  rectal  use  twice 
the  size  above  given. 


286  MALARIA 

Time  of  Administration. — To  the  infant  and  child  it  is  best  to  give 
quinin  at  regular  intervals  throughout  the  twenty-four  hours  when  not 
asleep.  The  doses  above  recommended  may  be  given  at  two-  to  four-hour 
intervals.  When  quinin  is  used  hypodermically  it  should  be  given  in  rather 
large  doses  about  three  hours  before  the  beginning  of  acute  symptoms.  In 
the  older  child  large  doses  of  quinin  should  be  given  four  hours  before  the 
beginning  of  the  expected  paroxysm. 

Apart  from  the  quinin  treatment,  the  management  of  a  case  of  acute 
malaria  must  be  purely  symptomatic.  During  the  chill  the  patient  may  be 
warmed  with  hot-water  bottles  and  additional  covering.  Phenacetin  and 
antipyrin  in  suitable  doses  may  be  given  just  before  or  at  the  beginning  of 
the  paroxysm  to  relieve  the  headache  and  make  the  patient  more  comfort- 
able. After  the  fever  rises  and  the  chill  disappears,  an  ice-bag  to  the  head 
or  sponging  the  body  with  cool  or  lukewarm  water  may  be  grateful  to  the 
patient.  If  constipation  exists  a  cathartic  should  be  given  in  the  interval 
between  paroxysms.  A  good-sized  dose  of  calomel  answers  this  purpose, 
and  by  many  observers  is  believed  to  promote  the  absorption  of  quinin.  The 
diet  during  the  acute  stage  should  be  carefully  selected  to  protect  the 
stomach  and  prepare  it  for  quinin  medication.  During  convalescence  the 
food  should  be  selected  with  reference  to  the  digestive  capacity  and  nutri- 
tional demands  of  the  child. 

Arsenic  is  a  very  valuable  remedy  in  convalescence  from  acute  malaria. 
It  acts  as  a  blood  tonic  and  prevents  relapses.  In  the  treatment  of  the 
chronic  forms  of  malaria,  especially  those  associated  with  enlarged  spleen, 
malarial  cachexia,  and  neuralgias,  arsenic  is  of  almost  as  much  value  as 
quinin.  To  young  children  it  may  be  administered  in  the  form  of  Fowler's 
solution;  to  older  children  arsenious  acid  may  be  given.  Fowler's  solu- 
tion should  be  given  in  some  palatable  vehicle,  such  as  essence  of  pepsin, 
one  minim  three  times  a  day  for  a  child  two  years  of  age  and  three  minims 
for  a  six-year-old  child.  Arsenic  should  be  administered  with  slight  in- 
terruptions for  a  period  of  two  months  and  during  a  portion  of  this  time 
should  be  combined  with  some  of  the  organic  iron  preparations.  In  younger 
children  Fowler's  solution  may  be  combined  with  one  of  the  malt  and 
organic  iron  preparations.  This  combination  is  effective  and  palatable.  In 
children  from  twelve  to  fourteen  years  of  age  the  following  prescription  is 
of  value : 

R     Acidi   arseniosi    14  gr. 

Ferri  reducti    20  grs, 

Quiniae  sulph    30  grs. 

20  capsules  put  up  dry. 

Sig.  One  after  eating. 


AGE  287 


CHAPTER  XXXVI 

WHOOPING  -COUGH 
(Pertussis) 

Whooping-cough  is  an  acute  infectious  disease  characterized  by  a  more 
or  less  violent  spasmodic  cough,  recurring  in  paroxysms,  accompanied  by 
the  expulsion  of  mucus  and  commonly  by  vomiting.  The  paroxysm  of 
coughing  is  interrupted  or  terminated  by  an  inspiratory  crow  or  whoop, 
which  gives  the  name  to  the  disease. 

Etiology. — The  "bacillus  pertussis"  of  Bordet  and  Genou  is  possibly 
the  specific  cause  of  this  disease.  These  observers  isolated  this  micro- 
organism from  the  pharyngeal  mucus,  and  Wollstein  observed  that  it  re- 
acted positively  to  agglutination  tests  with  the  blood  of  the  convalescent 
patient.  At  the  present  time,  however,  all  that  one  can  positively  say  is 
that  whooping-cough  is  caused  by  a  microorganism  whose  favorite  habitat  is 
the  pharynx,  larynx,  trachea,  and  bronchi,  and  that  the  common  exciting 
cause  of  the  cough  paroxysm  is  a  plug  of  laryngeal  or  bronchial  mucus. 
The  infectious  principle  of  whooping-cough  multiplies  rapidly  in  its  human 
host,  and  is  also  capable  of  affecting  dogs  and  cats.  It  is  not,  however, 
known  to  multiply  outside  the  bodies  of  its  hosts,  but  it  may  live  for  as  long 
as  ten  days  or  two  weeks  in  the  dried  state.  It  is  thrown  out  by  breathing, 
coughing,  or  sneezing;  the  mucus  thus  expelled  may  carry  the  contagion 
to  all  jjarts  of  the  room  and  may  deposit  it  on  the  clothing  of  the  doctor  or 
attendant,  who  in  turn  may  carry  it  to  a  third  party;  indirect  contagion, 
however,  is,  according  to  Morse,  a  very  rare  occurrence.  The  disease  is 
usually  communicated  by  the  well  coming  in  close  intercourse  with  the  sick, 
in  homes,  at  schools,  children's  parties,  and  other  public  gatherings.  There 
are  unusual  opportunities  for  the  sick  coming  in  contact  with  the  well  and 
thus  spreading  this  disease,  since  during  the  catarrhal  stage,  when  it  is 
most  infectious,  the  diagnosis  is  not  usually  made  and  the  child  is  not  ill 
enough  to  prevent  its  mingling  with  other  children  in  the  usual  pursuits  of 
life.  Quarantine  regulations  are,  therefore,  ineffectual  in  preventing  the 
spread  of  whooping-cough,  which  is  endemic  in  all  of  our  cities  and  which 
becomes  more  or  less  epidemic  every  two  or  three  years.  Epidemics  occur 
throughout  the  year;  cold  weather,  however,  increases  the  number  of  cases 
and  the  frequency  of  complications.  There  is  great  variability  in  the  viru- 
lency  of  different  epidemics ;  the  disease  may  prevail  in  either  a  mild  or  a 
severe  form. 

Age. — The  majority  of  exposed  individuals  contract  whooping-cough, 
but  susceptibility  is  not  so  general  in  this  disease  as  it  is  in  measles.  Nurs- 
ing infants  under  six  months  of  age  are  comparatively  immune;  the  dis- 
ease, however,  may  occur  even  in  the  new-born.  It  is  most  common  from 
the  end  of  the  first  to  the  beginning  of  the  fifth  year  of  life.  Fifty  per 
20 


288  WHOOPING-COUGH 

cent,  of  the  cases  occur  under  two  years  of  age,  so  that  the  second  year  of 
hfe  is  by  far  the  most  susceptible  period.  After  the  fourth  year  there  is  a 
gradually  diminishing  susceptibility.  Old  age  is  not  exempt;  I  knew  a 
physician  who  at  the  age  of  sixty-five  contracted  whooping-cough  after 
having  been  repeatedly  exposed  over  a  period  of  thirty-five  years  to  the 
contagion  of  the  disease, 

Neurotic  children  are  perhaps  not  more  susceptible,  but  they  have  this 
disease  in  a  more  severe  form.  Tuberculous  children  also  have  whooping- 
cough  very  severely ;  the  disease  aggravates  the  Ivmph-node  tuberculosis,  and 
the  tuberculosis,  on  the  other  hand,  by  enlarging  bronchial  lymph  nodes, 
causes  pressure  on  the  laryngeal  nerves,  which  may  prolong  the  spasmodic 
stage  of  whooping-cough  for  many  months. 

Period  of  Contagion. — The  catarrhal  stage  of  whooping-cough  is  very 
much  the  most  infectious  and  it  is  especially  during  this  period  that  the 
disease  is  spread.  It  is,  however,  also  contagious  during  the  spasmodic 
stage,  and  I  have  been  much  impressed  with  the  fact  that  the  contagion 
largely  disappears  very  early  in  this  stage.  I  have  again  and  again  seen 
children  during  this  period  of  the  disease  brought  into  contact  with 
other  children  in  their  outdoor  play  without  spreading  the  infection.  A 
quarantine  lasting  longer  than  five  weeks  is  unnecessary.  Second  at- 
tacks of  whooping-cough  are  extremely  rare.  The  immunity  con- 
ferred by  an  attack  is  as  safe  and  as  lasting  as  it  is  in  any  other  contagious 
disease. 

Incubation. — This  period  is  rather  uncertain;  it  probably  lasts  from 
six  to  ten  days.  Cases  are  reported  where  the  catarrhal  symptoms  have 
begun  within  the  first  thirty-six  hours  after  exposure. 

Symptomatology. — The  symptoms  are  divided  into  three  stages,  the 
catarrhal,  the  spasmodic,  and  the  convalescent. 

Catarrhal  Stage. — The  catarrhal  stage  begins  with  bronchitis,  pharyn- 
gitis, and  rhinitis;  the  pharynx,  nose,  throat,  and  eyes  are  usually  con- 
gested. The  cough  is  the  most  important  symptom;  it  soon  becomes  very 
irritating  and  harsh  and  is  associated  with  the  physical  signs  of  an  ordinary 
bronchitis  of  the  larger  tubes ;  it  is,  however,  more  irritating  and  harassing 
than  the  cough  of  ordinary  bronchitis  and  is  worse  at  night ;  in  the  begin- 
ning it  is  not,  as  a  rule,  paroxysmal,  but  it  is  so  hard  and  persistent  that 
the  child's  face  becomes  congested.  In  infants  the  cough  may  become 
paroxysmal  during  the  first  two  or  three  days  of  the  disease.  In  older 
children  the  duration  of  the  catarrhal  stage  differs  greatly,  but  usually 
during  the  second  week  the  cough,  which  has  continued  to  grow  worse,  be- 
comes more  paroxysmal,  and  the  typical  cough  of  the  spasmodic  stage  grad- 
ually develops.  There  is  a  slight  rise  of  temperature,  101°  to  102°  F., 
accompanied  by  headache  and  general  nervous  irritability.  With  the 
change  in  the  character  of  the  cough  the  fever  and  catarrhal  symptoms 
subside,  and  the  general  condition  of  the  child  improves. 

Spasmodic  Stage. — This  begins  at  the  end  of  the  first  or  second  week 
and  is  characterized  by  a  more  or  less  violent  spasmodic  cough,  which  re- 


SYMPTOMATOLOGY  289 

curs  in  paroxysms  and  is  commonly  interrupted  or  ended  by  an  inspiratory 
whoop;  mucus  is  expelled  and  vomiting  frequently  occurs.  The  cough, 
during  this  stage,  recurs  in  distinct  paroxysms,  with  longer  or  shorter  in- 
tervals of  rest,  and  the  child,  notified  of  the  approach  of  the  cough  by 
pharyngeal  irritation,  places  itself  in  a  position  to  withstand  the  approach- 
ing attack.  The  cough  is  violently  explosive  in  its  character  and  the  ex- 
plosive expirations  come  in  such  rapid  succession  that  after  a  time  respira- 
tion almost  or  entirely  ceases ;  this  is  followed  by  a  loud  sighing,  whooping 
inspiration,  accompanied,  as  a  rule,  by  the  expulsion  of  a  mass  of  frothy 
mucus  or  by  vomiting.  If  the  mucus  plug  is  not  removed  from  the  larynx 
the  attack  mav  be  immediately  repeated  and  followed  by  general  exhaustion 
and  muscular  relaxation.  During  the  paroxysm  the  child's  tongue  pro- 
trudes; its  face  becomes  red,  then  a  darker  hue,  and,  in  some  cases,  almost 
blue  or  cyanotic;  its  e3'es  bulge,  the  conjunctival  mucous  membranes  are 
congested,  and  the  whole  body  is  in  a  state  of  muscular  and  nervous  tension 
which  is  aggravated  by  the  sense  of  impending  danger  which  these  attacks 
inspire.  Tlie  above  description  represents  a  severe  paroxysm  of  whooping- 
cough.  These  attacks  may  be  much  milder  or  they  may  be  more  severe  and 
complicated  with  convulsions  and  other  profound  nervous  symptoms.  More 
or  less  emphysema  occurs  in  nearly  every  severe  case ;  it  is  especially  marked 
in  the  apices  of  the  lungs  and  in  rare  instances  the  lung  may  rupture, 
producing  pneumothorax  or  a  subcutaneous  emphysema.  Nose-bleed  and 
conjunctival  hemorrhages  frequently  occur;  the  latter  produce  the  blood- 
shot eye  so  commonly  seen  in  whooping-cough.  Hemorrhages  may  also  oc- 
cur from  the  throat,  the  bronchi,  and  the  ear;  in  rare  instances  the  ear- 
drum may  be  ruptured.  Incontinence  of  urine  and  of  feces,  especially  in 
young  children,  may  occur  during  the  attack.  A  grayish-white  ulcer  may 
develop  on  the  frenum  of  the  tongue  from  injury  to  and  subsequent  infec- 
tion of  this  organ.  Hernia  and  prolapse  of  the  rectum  may  result  from 
increased  abdominal  pressure.  Attacks  may  be  brought  on  by  fits  of  anger, 
excitement,  and  violent  exercise.  They  may  vary  in  duration  from  one 
to  fifteen  minutes,  depending  upon  their  severity.  The  duration  of  the 
spasmodic  stage  may  vary  from  two  weeks  to  two  months.  Enlargement  of 
the  bronchial  lymph  nodes  from  a  complicating  tuberculosis  may  prolong 
the  paroxysmal  cough  for  many  months.  Attacks  of  influenza  and  bron- 
chitis may  bring  back  the  paroxysmal  cough  months  after  the  child  is  ap- 
parently convalescent.  This  recurrence  is  strongly  suggestive  of  bronchial 
lymph-node  tuberculosis. 

During  the  convalescent  stage,  which  lasts  two  or  three  weeks,  all 
the  acute  symptoms  rapidly  subside.  The  bronchitis  ceases,  the  character- 
istic cough  loses  its  whoop,  becomes  much  milder,  less  paroxysmal,  and 
gradually  disappears. 

Blood. — In  whooping-cough  the  lymph  nodes  are  everywhere  enlarged, 
especially  in  the  neck  and  peribronchial  region.  To  correspond  with  this 
lymphatic  irritation  there  is  a  well-marked  leukocytosis,  varying  from 
20,000  to  40,000 ;  all  forms  are  increased,  but  the  lymphocytes  are  especially 


290 


WHOOPING-COUGH 


so.  The  lymphocytosis  is  both  relative  and  absolute  and  begins  before  and 
continues  through  the  paroxysmal  stage. 

Urine. — Slight  albuminuria  may  occur,  but  acute  nephritis  is  a  rare 
complication.     The  urine  may  contain  sugar  and  an  excess  of  uric  acid. 

Course. — Whooping-cough  is  a  self-limited  disease  running  its  course 
on  the  average  in  from  six  to  eight  weeks.  The  whooping-cough  paroxysms, 
however,  may  be  continued  much  beyond  this  period  from  enlargement  of 
the  bronchial  lymph  nodes.  The  lymph  node  enlargement  in  these  cases 
is  commonly  tuberculous.  In  all  cases  in  which  the  whooping-cough  par- 
oxysms continue  beyond  the  eighth  week  tuberculosis  should  be  suspected, 
and  the  treatment  should  be  the  same  as  elsewhere  given  for  lymph  node 
tuberculosis. 

Complications.  —Bronchopneumonia  is  the  most  serious  of  all  the  com- 
plications and  is  more  frequent  and  more  dangerous  in  infancy  than  in 


Fig.  47. — Pertussis  and  Measles  Complicated  by  Bronchopneumonia. 


childhood.  It  is  produced  by  streptococci,  staphylococci,  and  pneumococci, 
and  occurs  much  more  frequently  during  the  winter  months;  it  is  more 
commonly  seen  in  hospitals  and  tenement  houses  than  in  well-appointed 
homes.  Enterocolitis  is  a  much  dreaded  complication  of  whooping-cough 
in  infants  during  the  hot  months  and  is  responsible  for  no  small  part  of 
the  mortality  of  this  disease.  Tuberculosis  is  a  common  complication.  A 
latent  or  slightly  active  lymph-node  or  pulmonary  tuberculosis  may  be 
greatly  aggravated  into  serious  or  even  fatal  forms  of  tuberculosis.  Cardiac 
dilatation  and  weakened  heart  muscle  are  common  complications  and  se- 
quels of  severe  whooping-cough ;  they  are  manifested  by  shortness  of  breath 
and  by  an  irritable  and  rapid  pulse  which  is  easily  accelerated  by  exercise. 
Many  months  may  be  required  for  the  heart  muscle  to  regain  its  normal 
tone.  Measles,  diphtheria,  and  scarlet-fever  may,  especially  in  hospital 
practice,  occur  as  complications  of  whooping-cough  and  add  much  to  the 
gravity  of  the  prognosis. 

Diagnosis.— The  diagnosis  in  the  catarrhal  stage  is  very  difficult  and,  in 


TREATMENT  291 

the  great  majority  of  instances,  the  true  character  of  the  disease  is  over- 
looked until  the  characteristic  paroxysmal  cough  develops.  When  the  dis- 
ease is  epidemic,  or  when  it  occurs  during  the  summer  months,  its  presence 
may  be  suspected  early  and  a  blood  examination  may  confirm  the  diagnosis. 
Enlarged  bronchial  lymph  nodes  may  produce  a  symptom  group  resembling 
whooping-cough.  This  condition  is  nearly  always  tuberculous,  and  may  be 
differentiated  by  its  chronic  character  and  by  the  signs  and  symptoms  of 
l)roncliial  lymph-node  tuberculosis.  Adenoid  vegetations  may  cause  a 
paroxysmal  cough,  which  is,  however,  not  usually  associated  with  the 
whoop  and  the  after  vomiting  and  is  not  aggravated  at  night. 

Prognosis. — The  younger  the  child  the  more  dangerous  the  disease. 
Under  one  year  of  age  the  mortality  is  great  and  during  the  second  year  it 
continues  high ;  after  that  it  gradually  diminishes,  so  that  in  private  prac- 
tice the  disease  is  attended  with  little  danger  in  children  over  four  years 
of  age.  The  mortality  is  greater  during  the  winter  months,  when  chil- 
dren are  housed  and  ventilation  is  bad,  and  is  due  largely  to  broncho- 
pneumonia and  tuberculosis.  The  death  rate  of  whooping-cough  is  greatly 
increased  among  the  poor  during  the  summer  months  by  a  complicating 
enterocolitis.  W.  W.  Johnston  called  attention  to  the  fact  that  statistics 
showed  that  more  children  died  from  whooping-cough  in  the  United  States 
than  from  scarlet-fever,  and  he  estimated  that  100,000  children  die  from  it 
in  every  decade.  Statistics  in  European  countries  also  show  that  whoop- 
ing-cough is  scarcely  second  to  any  of  the  ordinary  acute  infections  in  its 
mortality  records,  and  yet  this  disease  is  treated  lightly  and  is  little 
dreaded  by  the  laity. 

Prophylaxis. — A  child  with  whooping-cough  should  be  carefully 
isolated  from  other  children,  especially  during  the  catarrhal  stage.  Abso- 
lute isolation  during  the  paroxysmal  stage  is  not  consistent  with  the  best 
forms  of  treatment,  and  is  not  in  the  vast  majority  of  instances  practicable. 
The  greatest  possible  effort,  however,  should  be  made  by  the  physician  to 
protect  children  under  three  years  of  age,  and  tuberculous  children  of  all 
ages,  from  coming  in  contact  with  the  contagion  of  whooping-cough.  It 
may  be  possible  for  the  well  to  occupy  the  same  playgrounds  with  whoop- 
ing-cough patients  who  are  in  the  late  paroxysmal  stage  of  this  disease, 
provided  this  is  done  under  proper  supervision,  but  well  children  should 
not  be  allowed  to  enter  a  room  that  has  been  occupied  by  a  whooping- 
cough  patient  until  that  room  has  been  thoroughly  disinfected. 

Treatment. — The  hygienic  treatment  of  this  disease  is  most  impor- 
tant. The  number  of  paroxysms  of  whooping-cough  will  depend  largely 
upon  the  contamination  of  the  air  in  which  the  patient  lives.  If  kept  in- 
doors in  ill-ventilated  apartments,  breathing  bad  air  contaminated  with 
dust,  germs,  and  carbonic  acid,  the  paroxysms  of  whooping-cough  will  be 
greatly  increased  in  number,  aggravated  in  severity,  and  the  pulmonary 
and  intestinal  complications  will  be  more  frequent.  The  most  important 
part  of  the  treatment,  therefore,  is  to  furnish  the  patient  with  the  purest 
air  possible,  both  by  day  and  by  night.     During  the  spring,  summer,  and 


292  WHOOPING-COUGH 

fall  months  it  is  a  comparatively  easy  matter  to  keep  the  patient  out  of 
doors  a  great  portion  of  the  time  without  causing  excessive  fatigue.  Dur- 
ing the  winter  months  the  child  should,  on  good  days,  spend  a  portion  of 
the  time  out  of  doors  and  while  indoors  should  live,  day  an'd  night,  in 
well-ventilated  rooms.  ^Miere  there  is  a  family  history  of  tuherculosis  it 
is  advisable  to  seek  a  milder  climate  for  whooping-cough  patients  during 
the  winter  months. 

Children  old  enough  to  lead  an  active  life  should  be  carefully  restricted 
as  to  exercise  during  the  severe  paroxysmal  stage.  Over-exertion  in- 
creases the  number  of  paroxysms  of  cough  and  throws  an  unnecessary  strain 
upon  a  heart  that  is  already  weakened  by  disease.  It  is  rarely  necessary, 
except  in  severe  complications,  to  forbid  all  exercise  by  confining  the  pa- 
tient to  bed. 

Dietetic  Treatment. — During  the  hot  summer  months  all  infants 
under  two  years  of  age  suffering  from  whooping-cough  should,  from  the 
very  beginning  of  the  disease,  be  most  carefully  dieted,  to  prevent  the  de- 
velopment of  that  much-dreaded  complication,  gastrointestinal  catarrh. 
They  should  be  removed  from  the  city  and  sent  to  a  place  where  they  can 
get  good  pure  air.  If  they  are  not  breast-fed,  the  artificial  food  formula 
upon  which  they  were  living  before  the  development  of  the  whooping- 
cough  should  be  reduced  in  strength  and  in  quantity;  infants,  for  ex- 
ample, nine  months  of  age,  who  have  been  taking  nine  or  ten  ounces  of  food 
every  four  hours,  should  be  given  five  or  six  ounces  every  three  hours,  and 
the  percentage  of  milk  in  the  formula  diminished.  If  intestinal  trouble 
develops,  then  every  attention  should  be  directed  to  its  correction  before 
it  becomes  a  gastrointestinal  catarrh;  it  may  be  necessary  to  peptonize 
the  milk  or  to  substitute  skimmed  milk  for  whole  milk  in  the  food  formula. 
At  any  rate  the  physician  should  be  impressed  with  the  importance  of 
using  prompt  dietetic  and  therapeutic  measures  for  preventing  entero- 
colitis in  young  infants  suffering  from  whooping-cough.  Careful  and  skil- 
ful feeding  is  required  to  maintain  the  general  nutrition  in  children  of  all 
ages  suffering  from  severe  attacks  of  whooping-cough.  Throughout  the 
disease  the  child's  diet  should  be  carefully  scrutinized,  giving  to  it  only 
such  foods  as  fall  easily  within  the  range  of  its  digestive  capacity,  and, 
since  a  full  meal  is  one  of  the  common  reflex  causes  of  the  whooping- 
cough  paroxysm,  it  is  advisable  that  the  child  should  be  fed  in  smaller 
quantities  at  shorter  intervals.  Beef-teas  and  highly  seasoned  foods  which 
may  cause  pharyngeal  irritation  and  thus  excite  the  cough  are  to  be 
avoided.  In  severe  cases  where  vomiting  follows  the  taking  of  food  the 
patient  should  again  be  fed  within  half  an  hour.  Food  taken  ten  or  twenty 
minutes  after  a  paroxysm  of  whooping-cough,  whether  tliat  paroxysm  be 
accompanied  by  vomiting  or  not,  is  usually  retained,  so  that  the  best  time 
to  feed  the  child  in  severe  cases  is  very  soon  or  directly  after  a  paroxysm. 
In  rare  instances  it  may  he  necessary  to  give  nutrient  enemata  of  some 
of  the  soluble  meat  preparations  or  of  peptonized  milk. 

Psychic  Treatment. — The  psychic  treatment  of  whooping-cough  is  of 


TEEATMENT  293 

importance  in  children  that  are  old  enough  to  be  thus  influenced;  this  is 
especially  true  of  neurotic  children.  They  should  be  shielded  from  ex- 
citement, should  be  taught  to  control  their  temper  and,  most  of  all,  should 
be  impressed  with  the  necessity  of  trying  to  postpone  or  control  whoop- 
ing-cough paroxysms. 

Kilmer  and  others  have  recommended  a  snugly  fitting  abdominal  elas- 
tic belt  surrounding  the  body  several  inches  above  and  below  the  region  of 
the  diaphragm.  This  elastic  bandage  is  applied  over,  and  attached  to  a 
much  wider  stockinet  band  which  is  held  in  position  above  by  shoulder 
straps.  Soper  recommends  that  traction  be  applied  in  such  a  way  as  to 
pull  both  angles  of  the  jaw  forward  and  downward.  It  is  believed  that 
these  devices  modify  the  severity  of  the  cough  and  diminish  the  frequency 
of  the  vomiting. 

Medical  Treatment. — At  the  present  time  the  local  treatment  of  the 
pharynx  is  not  in  vogue.  The  literature  of  whooping-cough  is  full  of  ad- 
vice on  this  subject,  the  details  of  which  need  not  be  repeated  here.  For- 
malin and  cresolin  vapors,  made  by  lamps  prepared  for  this  purpose,  may 
be  used  to  disinfect  the  room.  These  vapors  may  exert  a  favorable  influence 
on  the  whooping-cough  paroxysm,  but  should  never  be  used  at  the  expense 
of  fresh  air.  During  winter  months,  in  damp  northern  climates,  where  the 
patient  is  necessarily  confined  to  his  room  for  the  greater  portion  of  the 
twenty-four  hours,  and  where  ventilation  is  limited  to  the  partial  opening 
of  a  window,  or  where  fresh  air  is  obtained  by  removing  the  patient  from 
room  to  room  about  the  house,  both  cresolin  and  formalin  vapors  may  be 
used  to  advantage  in  disinfecting  the  air  that  the  patient  breathes.  Oil 
of  eucalyptus,  carbolic  acid,  and  creosote  in  vapor  form  are  also  recom- 
mended as  room  purifiers. 

Quinin  internally  is  the  most  valuable  remedy  we  have  in  the  treatment 
of  whooping-cough.  The  patient  may  have  an  idiosyncrasy  which  prevents 
the  administration  of  quinin,  and  in  young  children,  especially  in  infants, 
it  should  be  carefully  given  so  as  not  to  disturb  the  digestive  organs. 
This  is  true  of  every  drug  which  is  administered  to  modify  or  control  the 
paroxysms.  Whooping-cough  is  a  self-limited  disease  for  which  we  have 
no  specific  medication,  and  in  which  it  is  a  very  easy  matter  to  do  more 
harm  than  good  by  the  administration  of  drugs  which  disturb  the  gastro- 
intestinal organs,  weaken  the  heart,  tighten  the  cough  and  prevent  easy 
expectoration.  A  drug,  therefore,  that  is  of  real  value,  such  as  quinin, 
should  be  properly  used  and  not  abused.  In  children  old  enough  to  take 
capsules,  the  sulphate  of  quinin  should  be  given  in  from  3-  to  5-grain 
doses  three  times  a  day.  In  younger  children  euquinin  should  be  used; 
this  may  be  given  in  2-grain  doses  at  two  years  of  age,  and  3-grain  doses 
at  three  years  of  age.  I  am  a  firm  believer  in  the  eflficacy  of  the  quinin 
treatment  of  whooping-cough  and  employ  it  in  all  cases  where  it  is  possible, 
from  the  beginning  to  the  end  of  the  disease. 

As  a  routine  treatment  belladonna  in  some  form  may  be  administered. 
Jacobi,  for  many  years,  has  believed  this  drug  to  be  our  most  valuable  rem- 


294  WHOOPING-COUGH 

edy.  It  is  best  given  in  the  form  of  the  tincture,  in  doses  of  from  1  to 
3  minims,  depending  upon  the  age  of  the  child,  and  should  be  repeated 
three  or  four  times  in  twenty-four  hours.  If  the  severe  paroxysms  are  not 
in  any  way  modified,  the  dose  is  to  be  slightly  increased  day  by  day,  until 
its  physiological  effects  are  shown  in  the  dilated  pupils  or  the  flushed  face. 
Bromid  of  potash  is  a  valuable  remedy  for  modifying  the  paroxysms.  For 
a  child  two  years  of  age  the  dose  should  be  3  grains  every  four  hours, 
increasing  it  1  grain  for  every  year  of  life.  The  bromid  of  potash  and  the 
belladonna  may  be  combined  in  the  same  prescription.  In  whooping-cough, 
more  than  in  almost  any  other  disease,  medicines  should  be  given  only 
when  they  are  positively  indicated,  but  in  cases  requiring  treatment  the 
ordinary  routine  should  be  quinin  three  times  a  day,  and  bromid  of  potash 
with  tincture  of  belladonna  in  a  proper  vehicle  four  times  a  day.  Anti- 
pyrin,  in  from  1  to  4-grain  doses,  to  suit  the  age  of  the  child,  has  a  marked 
influence  in  relieving  the  paroxysmal  cough,  but  its  depressing  action 
on  the  heart  demands  that  it  should  be  used  judiciously  and  for  only  a 
short  period  of  time.  Chloral  hydrate  is  an  hypnotic  of  some  value  in 
severe  cases;  it  should  be  given  in  from  2  to  5-grain  doses  at  four  o'clock 
in  the  afternoon  and  at  bedtime.  The  opium  preparations  may  be  recom- 
mended in  older  children  for  the  control  of  the  paroxysmal  cough.  Of 
these,  paregoric  (10  to  20  drops),  sulphate  of  codein  (1/50  to  1/8  grain), 
heroin  hydrochlorate  (1/100  to  1/20  of  a  grain)  and  bimecinate  of  mor- 
phin  (1/2  to  1  gtt)  are  the  most  valuable.  These  preparations,  however, 
have  no  field  of  usefulness  in  the  treatment  of  whooping-cough  in  children 
under  two  years  of  age.  A  record  of  the  number  of  paroxysms  occurring 
in  twenty-four  hours  should  be  kept  as  an  indication  of  the  value  of  any 
form  of  treatment.  Tincture  of  strophanthus  and  tincture  of  digitalis  may 
be  indicated  in  those  eases  where  the  pulse  is  weak  and  the  heart  muscles 
dilated.  The  vaccine  treatment  of  whooping-cough  has  not  been  notably 
successful.  When  whooping-cough  occurs  in  a  child  in  whom  there  is  a 
suspicion  of  latent  tuberculosis,  the  child  should  be  actively  treated  for  the 
latter  disease,  as  outlined  under  the  Treatment  of  Glandular  Tuberculosis. 
Pneumonia,  the  most  dreaded  complication,  is  to  be  watched  for  and  treated 
on  the  appearance  of  its  earliest  symptoms.  If  one  makes  the  mistake  of 
beginning  the  treatment  for  tuberculosis  or  pneumonia  when  these  compli- 
cations are  not  present,  no  harm  is  done,  while,  on  the  other  hand,  the 
patient's  life  may  be  lost  by  beginning  the  treatment  too  late. 


ETIOLOGY  295 

CHAPTER    XXXVII 
DIPHTHERIA 

Diphtheria  is  an  acute  infectious  disease  produced  by  the  Klebs-Loffler 
bacillus.  It  manifests  itself  by  the  development  and  growth  of  a  grayish- 
white  membrane,  usually  located  in  the  throat  and  air  passages.  In 
these  foci  the  bacilli  manufacture  a  very  potent  constitutional  poison,  the 
absorption  of  which  is  responsible  for  the  toxic  symptoms  of  this  disease. 

Etiology. — The  Klebs-Loffler  bacillus,  which  is  the  specific  etiological 
factor  in  every  case  of  diphtheria,  is  rod-shaped,  from  2  to  4  /i  in  length 
and  from  0.4  to  0.8  pi  in  width.  It  may  be  straight  or  slightly  curved  and 
clubbed  at  the  ends.  It  grows  readily  in  common  culture  media,  but  best 
on  Loffler's  blood  serum,  showing  within  twelve  hours  a  grayish-white 
growth.  It  is  non-motile,  aerobic  and  does  not  liquefy  the  blood  serum.  It 
grows  most  rapidly  at  the  temperature  of  the  body,  in  a  neutral  or  slightly 
alkaline  media;  acids  and  strong  alkalies  inhibit  its  growth.  It  is  grad- 
ually destroyed  by  the  action  of  sunlight  and  quickly  killed  by  a  tempera- 
ture of  136 °F.  Cold  inhibits,  but  does  not  kill  it.  It  may  live  for  months 
in  a  dried  state  in  clothing,  bedding  and  carpets,  and  the  disease  may  be 
spread  by  the  belongings  of  the  sick  room  and  the  clothing  of  the  attend- 
ants. It  is  not  uncommonly  found  in  the  throats  of  healthy  individuals, 
who  may  act  as  carriers  of  the  disease  to  others  with  more  susceptible 
mucous  membranes.  In  milk  it  lives  and  multiplies  slowly,  and  epidemics 
may  be  produced  in  this  way.  W.  H.  Park  found  that  guinea-pigs,  chick- 
ens, birds,  cats,  rabbits,  dogs,  cattle  and  horses  were  susceptible  to  this 
disease. 

Human  intercourse  is  the  great  cause  of  its  spread.  The  contagion 
lies  in  the  discharges  which  come  from  the  local  foci,  usually  located  in 
the  throat  and  nose.  This  bacillus  is  not  readily  carried  through  the  air, 
and  closer  contact  with  the  sick  is  necessary  for  the  spread  of  this  disease 
than  for  many  other  contagions,  such  as  measles,  small-pox  and  scarlet 
fever.  Crowded  tenements,  schools  and  children's  parties,  which  bring  into 
intercourse  the  sick  with  the  well,  are  important  factors  in  the  spread  of 
diphtheria,  since  the  carriers  of  this  infection  are  very  common  among  those 
who  are  apparently  well. 

Diphtheria  is  rare  in  young  and  nursing  infants.  This  immunity  is 
probably  due  to  immune  bodies  derived  from  the  placental  blood  and  is  con- 
tinued by  nursing  milk  from  the  breast  of  an  immune  mother.  It  is  most 
common  between  the  second  and  sixth  year  of  life;  after  this,  susceptibil- 
ity gradually  diminishes,  until  in  the  adult  it  is  comparatively  rare.  One 
attack  confers  immunity,  but  this  is  temporary  and  may  last  but  a  few 
months.  Second  attacks  following  rather  closely  upon  the  previous  attack 
are  comparatively  mild.  Catarrhal  conditions  of  the  throat  and  nose  and 
chronic  disease  of  the  tonsils  and  adenoids  are  predisposing  causes.    Diph- 


296  DIPHTHERIA 

theria  is  more  common  in  winter  than  in  summer.  It  is  more  prevalent 
in  cities,  but  it  occurs  very  unaccountably  at  times  in  epidemic  form  in 
remote  country  districts. 

Pathology. — Diphtheria  is  primarily  a  local  disease;  its  symptoms  are 
largely  due  to  the  action  of  toxins.  In  prolonged  cases  more  or  less  gen- 
eral infection  with  the  diphtheria  bacillus  may  occur.  In  these  cases 
bacilli  may  be  found  in  the  blood,  lymphatic  tissues,  liver,  kidneys  and 
other  organs.  The  local  lesions  on  the  tonsils,  soft  palate,  and  uvula,  or  in 
the  nose,  larynx,  and  other  respiratory  passages,  consist  of  an  inflammation 
of  the  mucous  membrane,  which  becomes  hyperemic,  swollen  and  infil- 
trated with  cells.  This  is  followed  by  the  appearance  of  a  grayish-white, 
sometimes  brownish,  pseudo-membrane,  first  occurring  in  patches  and  then 
spreading  and  forming  a  more  or  less  continuous  covering  for  the  part 
affected.  The  severity  of  this  process  may  vary  from  a  mild  pseudo-mem- 
branous sore  throat  to  a  necrosis,  subsequent  sloughing  and  destruction  of 
the  parts  affected.  An  early  myocarditis  with  acute  cardiac  dilatation  may 
occur,  or  slower  changes  may  take  place  in  the  heart  muscle,  producing  a 
fatty  degeneration  of  the  muscle  fiber,  with  a  resulting  replacement  fibrosis 
and  infiltration  with  small  round  cells.  In  the  nerves  we  may  have  degen- 
erative processes,  both  parenchymatous  and  interstitial,  which  completely 
destroy  their  function.  The  sensory  as  well  as  the  motor  nerves  may  be 
affected.  In  the  anterior  horns  of  the  spinal  cord  hemorrhages  and  de- 
generative changes  may  occur.  If  the  disease  is  prolonged  sepsis  becomes 
a  part  of  the  pathological  process,  and  may  manifest  itself  by  the  ordinary 
lesions  of  a  general  septicemia  or  septicopyemia. 

Incubation  Period. — This  lasts  from  one  to  four  days,  and  during  this 
period  there  are  no  symptoms. 

Symptomatology.  — The  ordinary  form  of  diphtheria  begins  with  a  sore 
throat.  The  tonsils  and  pharynx  are  swollen,  congested,  and  j^resent  one 
or  more  grayish-white  patches  which  coalesce,  forming  a  pseudo-membrane 
that  gradually  takes  on  a  grayish-brown  color.  It  may  spread  over  the 
tonsils,  uvula  and  pharynx,  and  may  extend  into  the  nose  or  through  the 
larynx  down  the  trachea  into  the  bronchial  tubes.  Hand  in  hand  with  the 
extension  of  this  membrane  the  local  inflammatory  conditions  in  the  throat 
are  increased,  so  that  the  patient  may  complain  more  and  more  of  diffi- 
culty in  swallowing.  The  odor  from  the  breath  may  become  fetid.  The 
lymph  nodes  at  the  angle  of  the  Jaw,  which  are  always  enlarged,  may  be- 
come more  and  more  swollen,  involving  the  intervening  connective  tissue, 
producing  a  doughy-like  swelling  in  the  region  of  these  glands.  The  pseudo- 
membrane  may  not  only  be  seen  in  the  locations  described,  but  as  the 
disease  progresses  it  may  be  coughed  up  or  discharged  from  the  nose,  and 
with  the  breaking  loose  of  these  membranes  hemorrhages  may  occur.  In 
mild  cases  the  above  local  symptoms  are  very  much  modified,  so  much  so 
that  the  patient  may  scarcely  be  conscious  that  he  has  anything  more  than 
a  very  mild  tonsillitis;  in  the  severe  cases  they  may  be  greatly  aggravated 
by  the  necrotic  and  gangrenous  processes  which  occur. 


SYMPTOMATOLOGY 


297 


There  may  be  headache,  backache,  general  malaise,  and  an  early  rise  of 
temperature  reacliing  in  the  first  twenty-four  hours  102°  to  104°  F.  The 
fever,  as  a  rule,  commences  to  fall  within  twenty-four  or  thirty-six  hours; 
in  uncomplicated  cases  it  may  reach  normal  within  a  few  days.  A  sec- 
ondary rise  is  due  to  some  complication,  usually  of  septic  origin ;  when  this 
occurs  the  temperature  runs  the  irregular  course  of  septicopyemia.  The 
temperature  may  vary  greatly ;  in  the  most  virulent  cases  it  may  be  normal 
or  even  subnormal,  so  that  from  a  diagnostic,  as  well  as  a  prognostic, 
standpoint  it  may  be  very  deceptive. 

The  general  prostration  of  the  patient  during  the  first  twenty-four 


D»V 
OF   MONTH 

g 

CM 

S 

Oi 

CO 
CM 

0*V 
OF  DISEASE 

e» 

n 

TT 

IT 

CO 

a  I 
TIME            ^   ^ 

2  i 

0.      0. 

'i 

a  »   a    4  a 

<    -i    <    i    cl 

i   a       a  I    s    o 

ax    a  ^  a  z 

i » « » !i  « 

Uil 

■^    3 

a 
< 

i 

il 

a  2 

-    3 

107° 

inii° 

1 

i 

l> 

W_ 

1 

1- 

° 

ATUR 

"^^A^ 

^. 

* 

S           I 

7   " 

1 

f 

t^ 

J.     102  -j 
t     ini°-i 

v 

n1 

z           1 

z 

u    inn° 

\..'- 

:^A 

X 

2      99^ 

'A. 

v^. 

', 

,       J 

L 

X 

i^5 

<             ^- 

,'      \ 

t' 

'v 

l\ 

.1 

t** 

1; 

»*? ... 

K' 

w' 

.^ 

/ 

87    ■^ 

< 

1 

> 

9 

> 

L^ 

i 

t 

t»8 

PUISE            §    5 

3,    Si   » 

S   s 

9    « 

°   X 

§  s  8  s  a 

S  S   S  S   s  g   5 

t!  8  S   S   S   S 

1  =  1  s 

S  S 

•  1 

s 

3 

S  3 

S        II 

1  RESPIRATION      S   S 

R  S   8 

s  n 

s;  Vi 

S   3 

s  s  s  a  « 

S  S   S   !3  «   S   S 

Z  TK  t   »   ^   S 

i  s  *  a 

g    R 

ii 

o 

S 

S  S 

g        II 

Fig.  48. — Pharyngeal  Diphthebia  Treated  with  Antitoxin. 


hours  of  the  disease  is  an  important  prognostic  sign.  The  more  profound 
the  prostration  the  more  severe  the  intoxication.  In  the  most  violent 
cases  the  patient  is  almost  at  once  overwhelmed  by  the  toxemia.  Extreme 
prostration,  high  fever,  rapid,  feeble,  irregular  pulse  with  profound  nerv- 
ous symptoms,  such  as  stupor,  coma  and  convulsions,  may  be  associated 
with  hemorrhages  from  the  mucous  membranes,  and  with  a  purpuric  rash 
over  tlie  body.  These  foudroyant  cases,  which  may  die  within  the  first  two 
days,  are  fortunately  very  rare. 

The  blood  presents  no  characteristic  changes.  There  is  a  simple 
anemia  and  a  marked  leukocytosis,  sometimes  as  high  as  48,000.  The 
polymorphonuclears  are  usually  increased. 

Laryngeal  diphtheria  may  be  primary  or  secondary;   fatal   cases 


298 


DIPHTHERIA 


are  seen  where  the  throat  and  pharynx  present  no  evidence  of  a  pseudo- 
membrane.  A  slight  pseudo-membrane  behind  the  pillars  of  the  fauces 
may  have  been  overlooked,  but  it  is  well  to  keep  in  mind  the  fact  that 
laryngeal  diphtheria  in  rare  instances  occurs  with  little  or  no  preceding 
evidence  of  sore  throat.  The  membrane,  however,  in  a  great  majority  of 
the  cases  extends  from  the  throat  into  the  larynx,  and  the  symptoms  of 
laryngeal  diphtheria  are  therefore  commonly  preceded  by  some  evidences  of 
tonsillar  or  pharyngeal  diphtheria.  In  extremely  rare  instances  it  is  be- 
lieved that  the  membrane  may  occur  primarily  in  the  trachea  or  bronchial 
tubes  and  ascend  to  the  larynx.     The  diagnosis  of  tracheal  or  below-the- 


OAV 
OF  MONTH 

g 

CO 

€■» 

- 

c>< 

OAV 
OF  DtSEASe 

ex 

c; 

^ 

« 

IS 

TtME 

a; 

s 

2 
a 

7i 

0. 

2 

a 
< 

< 

a 
< 

1 

a 

i 

a 

•5 

a' 

< 

a 
< 

1 

2 

a 

ai 

a 

a 

< 

< 

a 
< 

1 

a 

z 

0^ 

a 

a 

z* 

a 

J 

a 

a. 

» 

a 

a 

a 
< 

n 

z 
< 

FAHRENHEIT    TEMPERATURE 

? 

? 

? 

? 

? 

s* 

g" 

2" 

= 

i 

1 

1 

V 

1 

:i: 

* 

2 

5 

s 

3 

3 

1 

1 

1 

1 

1 

< 

1 

< 

r 
/ 

1 

\ 

\ 

r 
/ 

J 

r. 

V 

\ 

, 

1 
1 

i 
1 

/ 

1 

\ 

\ 

V 

\ 

\ 

K 

s 

1 

/ 

V 

^ 

V 

" 

y 

^ 

N 

Si 

** 

> 

s 

s 

^ 

t 

7t^ 

\ 

1 

■^ 

/ 

s 

r 
^ 

s 

< 

V 

V 

^ 

'^ 

^ 

^ 

f 

s 

•■« 

> 

a. 

o 

V 

1, 

i 

;^ 

ii 

1 

s 

^ 

r 

1 

S 
0. 

1 

1 

4 

9 

s 

1 

> 

PUISE 

I 

£ 

1 

1 

s 

i 

: 

3 

o 

■^ 

s 

5 

II 

e 

3 

2 

S 

2 

^ 

II 

s 

5 

3 

a 

s 

3 

2 

<l 

s 

5 

s 

:; 

o 

» 

= 

0 

o 

RESPIRATION 

<C 

2 

_!_ 

1 

8 

tt 

S 

IS! 

•• 

a 

« 

^ 

II 

«! 

« 

s 

s 

s 

S 

j. 

£ 

H 

« 

SI 

« 

» 

s 

n 

8 

?! 

5 

% 

s 

S 

1 

s 

FiQ.  49. — Labyngeal   Diphtheria  Treated  by   Intubation  and  with  Antitoxin. 

larynx  diphtheria  is  made  by  the  coughing  up  of  membranous  casts  from 
the  trachea  or  bronchial  tubes  and  by  the  failure  of  laryngeal  operations 
to  relieve  the  stenosis,  and  also  perhaps  by  the  evidence  of  unilateral  block- 
ing of  the  bronchial  tubes  as  made  out  by  percussion  and  auscultation. 

.  The  classical  symptoms  of  laryngeal  diphtheria  are:  a  croupy  cough 
of  metallic  character,  increasing  in  severity  and  associated  with  a  gradually 
increasing  hoarseness,  dyspnea,  and  loss  of  voice.  The  dyspnea  is  slightlv 
worse  at  night,  and  slowly  increases  in  severity  day  by  day  until  the  stridor 
and  labored  breathing  may  be  heard  in  all  parts  of  the  room.  On  the 
third  or  fourth  day  the  membrane  in  the  larynx  may  cause  complete  ob- 
struction and  end  the  life  of  the  patient  by  suffocation.  As  -the  breathing 
becomes  more  and  more  difficult,  the  patient  sits  up  in  bed  and  fights  for 


COMPLICATIONS  299 

air.  All  the  accessory  muscles  of  inspiration  are  brought  into  play  as  the 
child  with  tremendous  effort  attempts  to  force  air  into  the  lungs;  the  alae 
of  the  nose  are  dilated,  the  suprasternal  notches  are  sunken  in,  the  dia- 
phragmatic groove  is  contracted,  and  the  whole  attitude  of  the  patient  is 
characteristic  of  air  hunger.  The  croupy  cough  comes  on  in  paroxysms, 
is  very  persistent  and  is  only  temporarily,  if  at  all,  relieved  by  vomiting. 

Diphtheria  of  the  Eye. — True  diphtheritic  ophthalmia,  before  the 
days  of  antitoxin,  was  one  of  the  most  dreaded  of  all  the  complications  of 
this  disease,  and  it  is  still  much  feared  because  it  so  frequently  results  in 
loss  of  sight.  The  conjunctiva  is  violently  inflamed  and  covered  with  a 
white  or  gray  membrane.  There  is  a  profuse  purulent  discharge  and  the 
lids  are  so  swollen  that  they  can  be  separated  with  difficulty.  The  cornea 
quickly  becomes  involved  and  its  destruction  may  cause  loss  of  vision. 

Diphtheria  of  the  Vulva. — This  is  a  rare  complication,  but  it  may 
occur  in  infants  as  a  result  of  direct  inoculation.  The  parts  are  much 
inflamed,  swollen  and  covered  with  a  pseudo-membrane.  These  cases  com- 
monly run  a  benign  course  and  terminate  in  recovery. 

Paralysis.- — The  heart  may  suffer  both  early  and  late  in  the  disease  in 
the  acute  onslaught  of  very  severe  cases;  asystole  and  diminished  systole 
may  result  from  splanchnic  paralysis.  During  the  second  or  third  week 
vomiting,  abdominal  pain,  cardiac  gallop  rhythm  and  irregular  respiratory 
movements  usuall}^  mean  the  involvement  of  the  pneumogastric  nerve. 
In  both  of  these  conditions  there  is  imminent  danger  of  cardiac  paralysis. 
Between  the  third  and  the  sixth  week  fatty  degeneration  of  the  heart  muscle 
with  cardiac  dilatation  may  occur,  and  the  heart's  action  may  become  ir- 
regular, intermittent  and  feeble,  and  s.  slight  murmur  may  appear  at  the 
apex.  These  cases,  however,  commonly  make  a  slow  recovery,  the  cardiac 
weakness  persisting  for  months  after  convalescence  has  been  established. 
It  should  be  remembered  that  a  moderate  degree  of  irregularity  and  dis- 
turbance of  the  cardiac  rhythm  may  occur  at  any  period  of  the  disease 
without  necessarily  indicating  serious  cardiac  involvement,  but  when  the 
symptoms  of  splanchnic  or  vasomotor  paralysis  appear  the  life  of  the  pa- 
tient is  in  imminent  danger. 

The  post-diphtheritic  form  of  paralysis  commonly  occurs  during  ap- 
parent convalescence,  from  two  to  five  weeks  after  the  onset  of  the  initial 
symptoms,  and  its  appearance  may  confirm  an  uncertain  diagnosis.  This 
form  commonly  begins  in  the  palate  and  is  made  evident  by  the  nasal  tone 
of  the  speech  and  by  difficulty  in  deglutition;  fluids  taken  into  the  mouth 
sometimes  return  through  the  nose.  In  these  cases  the  patellar  reflex 
should  be  studied  as  an  indication  of  the  probable  extension  of  the  paraly- 
sis; the  absence  of  this  reflex  indicates  approaching  paralysis  of  the  legs. 
This  may  be  followed  by  paralysis  of  the  muscles  of  the  eyes,  arms  and 
trunk,  gradually  resulting  in  complete  paralysis  of  almost  all  the  voluntary 
muscles.  The  prognosis  in  this  form  of  paralysis  is  favorable ;  a  slow  but 
complete  recovery,  extending  over  months,  usually  takes  place. 

Complications. — General  septicemia,  or  a  septicopyemia,  are  common 


300  DIPHTHBKIA 

complications  of  diphtheria,  and  the  course  of  the  sepsis  is  similar  to  that 
described  under  Scarlet  Fever.  Severe  cases  of  this  character  are  usually 
associated  with  ulcerative  and  gangrenous  sore  throats,  and  with  extensive 
cervical  adenitis,  involving  the  cellular  tissue  of  the  neck,  which  may  or 
may  not  terminate  in  suppuration.  This  local  symptom  group  is  accom- 
panied by  profound  constitutional  symptoms,  such  as  marked  prostration, 
a  septic  fever  or  subnormal  temperature,  a  feeble,  intermittent  pulse  and 
stupor,  deepening  into  a  semi-comatose  condition. 

Otitis  media,  mastoiditis  and  purulent  infections  of  the  frontal  and 
ethmoidal  sinuses  may  occur. 

Bronchopneumonia  is  the  most  dreaded  of  all  the  complications.  It 
occurs  most  frequently  in  septic  and  in  laryngeal  cases;  it  is  especially  to 
be  feared  following  tracheotomy  and  intubation  for  laryngeal  stenosis.  It 
is  found  in  50  to  70  per  cent,  of  fatal  cases.  The  onset  is  marked  by 
an  increase  in  the  fever,  cough  and  dyspnea,  and  a  careful  physical 
examination  reveals  either  a  unilateral  or  a  bilateral  bronchopneu- 
monia. 

Nephritis,  according  to  Baginsky,  occurs  in  42  per  cent,  of  the  severe 
cases.  It  is,  however,  a  rather  uncommon  complication  of  the  mild  cases, 
and,  as  this  type  of  the  disease  greatly  predominates,  it  does  not  perhaps 
occur  in  more  than  5  to  10  per  cent,  of  all  cases;  a  slight  albuminuria, 
however,  is  observed  in  about  30  or  40  per  cent. 

Simple  enteritis  occ.urs  very  frequently,  but  pseudo-membranous  gas- 
troenteritis is  very  rare;  when  present,  however,  it  usually  causes  a  fatal 
termination. 

Course  and  Duration. — In  simple  tonsillar  and  pharyngeal  diphtheria, 
the  acute  symptoms  last  from  three  to  five  days.  In  cases  which  are  com- 
plicated by  septic  infection  the  disease  may  be  indefinitely  prolonged. 
The  antitoxin  treatment  greatly  shortens  the  course  and  modifies  the  se- 
verity of  the  disease. 

Frogncsis.- — Age  is  a  very  important  prognostic  factor.  During  the 
first  year  the  death  rate  is  50  per  cent.,  the  second  year  30  per  cent. ;  after 
the  seventh  year  7  or  8  per  cent.  The  severity  of  the  infection  is  a  deter- 
mining factor  in  the  prognosis;  some  epidemics  are  very  malignant,  others 
are  very  mild;  the  character,  therefore,  of  the  prevailing  epidemic  may 
assist  in  determining  the  prognosis  in  an  individual  case.  The  parts  af- 
fected very  materially  influence  the  prognosis;  in  laryngeal  and  tracheal 
diphtheria  the  death  rate  may  reach  60  to  70  per  cent.;  in  severe  nasal 
diphtheria,  with  a  complicating  sepsis,  the  prognosis  is  also  serious;  in 
simple  tonsillar  diphtheria  the  prognosis  is  good.  The  previous  condition 
of  the  patient  may  determine  in  part  his  powers  of  resistance,  and  may, 
therefore,  influence  the  prognosis;  in  feeble,  malnourished  children  the 
prognosis  is  not  as  good.  The  treatment  is  the  important  determining  fac- 
tor in  the  prognosis.  If  antitoxin  is  given  within  the  first  twenty-four 
hours,  less  than  5  per  cent,  die;  within  the  second  twenty-four  hours,  less 
than  10  per  cent.;  within  the  third  twenty-four  hours,  about  20  per  cent.; 


DIAGNOSIS  301 

within  the  fourth  twenty-four  hours,  about  40  per  cent.  In  the  laryngeal 
cases  the  death  rate  is  reduced  by  antitoxin  from  (55  to  25  per  cent. 

Diagnosis. — For  the  diagnosis  of  this  disease  the  physician  must  depend 
first  upon  his  clinical  observations,  and  second  upon  the  bacteriological 
findings.  The  clinical  diagnosis  is  made  by  the  appearance  of  a  pseudo- 
membrane  on  the  tonsils,  uvula,  pharyngeal  wall,  and  sometimes  in  the 
nose  and  in  the  larynx,  when  it  is  not  visible  elsewhere.  In  most  instances 
there  is  nothing  absolutely  pathognomonic  in  the  appearance  of  this  mem- 
brane, but  the  physician  comes  by  experience  to  learn  that  grayish-white 
patches  of  pseudo-membrane,  having  a  tendency  to  spread,  and  located  as 
above  noted,  usually  mean  diphtheria,  and  that  all  such  cases  should  have 
antitoxin  at  once  before  the  result  of  the  bacteriological  examination  denies 
or  confirms  the  correctness  of  his  diagnosis.  The  bacteriological  findings 
are  of  the  utmost  importance,  and  if  made  early  in  the  disease  are  more 
reliable  than  the  clinical  appearances.  But  it  should  be  remembered  that 
they  are  by  no  means  infallible;  for  instance,  in  rare  cases  pseudo-diph- 
theria bacilli  may  cause  confusion,  or  again  the  membrane  may  be  so  lo- 
cated in  the  air  passages  that  it  is  not  reached  by  the  cotton-wrapped  probe 
from  which  the  culture  is  made,  or  late  in  the  disease  pyogenic  cocci  and 
other  microorganisms  may  have  so  replaced  the  diphtheria  bacilli  that 
they  are  not  found  in  the  culture.  Clinical  and  bacteriological  findings, 
therefore,  should  go  hand  in  hand.  When  they  agree,  as  they  do  in  most 
instances,  there  is  no  question  as  to  the  diagnosis ;  when  they  disagree  the 
patient  should  have  the  benefit  of  the  doubt  and  be  given  antitoxin,  and 
the  subsequent  history  of  the  case  will  determine  the  wisdom  of  this  action. 
From  the  standpoint  of  preventive  medicine,  the  laboratory  diagnosis  is 
all-important.  It  is  relied  upon  to  determine  whether  a  quarantine  shall 
be  established  and  when  it  is  to  be  discontinued.  Patients  should  not  be 
discharged  until  a  negative  throat  culture  has  been  obtained.  Paralysis 
of  the  soft  palate  and  other  post-diphtheritic  paralyses  may  often  make 
a  late  diagnosis  of  diphtheria  in  cases  that  were  supposed  to  have  suffered 
from  follicular  tonsillitis.  The  paralysis  which  follows  diphtheria  is  a 
neuritis  and  is  to  be  differentiated  from  infantile  paralysis  and  cerebral 
palsy;  this  differentiation,  however,  is  taken  up  under  the  latter  disease. 
It  is  only  important  here  to  note  that  a  paralysis  which  occurs  with  or 
follows  a  membranous  sore  throat  and  which  begins  in  the  palate  is,  in 
almost  every  instance,  due  to  diphtheritic  neuritis.  Traumatic  pseudo- 
membranes  following  operations  on  the  tonsils,  or  injury  to  the  throat  or 
mouth  from  caustic  alkalies,  may  be  differentiated  from  true  diphtheria 
by  bacteriological  findings  and  by  the  previous  history  and  symptomatology. 

Diphtheritic  laryngitis  may  be  differentiated  from  spasmodic  catarrhal 
croup  by  the  following  points:  In  catarrhal  laryngitis  the  attack  of  croup 
comes  on  suddenly,  usually  in  the  early  part  of  the  night ;  the  child  wakes 
up  with  a  hoarse,  barking  cough,  struggles  for  breath  and  has  a  laryngeal 
stridor  that  can  be  heard  in  all  parts  of  the  room.  The  attack  reaches 
its  height  the  first  night;  the  next  day  the  child  is  comparatively  com- 


302  DIPHTHERIA 

fortable,  with  perhaps  a  little  hoarseness  and  croupy  cough ;  the  second  and 
third  nights  the  attack  may  be  repeated,  but  grows  less  severe.  In  laryn- 
geal diphtheria,  however,  the  laryngeal  stridor  comes  on  more  slowly,  grad- 
ually increasing  in  severity  for  three  or  four  days,  until  the  child's  life 
is  imperilled  by  strangulation;  the  stridor  also  continues  throughout  the 
day ;  it  may  be  worse  at  night.  The  presence  of  a  membrane  in  the  throat, 
and  a  bacteriological  examination,  may  assist  in  the  diagnosis.  An  emetic, 
which  gives  such  prompt  relief  in  simple  laryngitis,  has  little  influence  on 
the  laryngeal  stridor  of  diphtheritic  croup.  If  necessary  the  administra- 
tion of  chloroform  may  be  resorted  to,  to  assist  in  the  diagnosis ;  cliloroform 
relieves  the  stenosis  of  simple  laryngitis,  but  has  little  influence  in  laryn- 
geal diphtheria. 

Prophylaxis. — As  a  matter  of  general  prophylaxis  all  children  having 
diseased  tonsils,  adenoids  or  nasal  mucous  membranes  should  have  these 
parts  properly  treated,  and,  if  possible,  put  in  normal  condition  so  that 
they  may  be  less  predisposed  to  contagion.  Children  who  have  been  ex- 
posed to  diphtheria  should  be  given  an  immunizing  dose  of  from  500  to 
1,000  units  of  antitoxin  and  should  also  have  their  throats  and  noses  care- 
fully douched  with  physiological  salt  solution,  or  with  some  alkaline  anti- 
septic. In  exposed  institutional  children  the  immunizing  dose  of  antitoxin 
should  be  repeated  in  three  weeks. 

Although  the  radius  of  infection  in  diphtheria  is  more  contracted  than 
it  is  in  most  of  the  contagious  diseases,  the  patient  should  be  isolated  and 
a  rigid  quarantine  instituted,  which  should  be  continued  until  convalescence 
is  established  and  until  a  bacteriological  examination  of  the  throat  has 
demonstrated  that  it  is  free  from  diphtheria  bacilli.  The  preparation  of 
the  sick  room  and  other  details  of  quarantine  are  described  in  the  chapter 
on  Scarlet  Fever.  In  the  average  case  of  diphtheria  the  quarantine 
lasts  two  weeks. 

Treatment.  ■ — In  diphtheria  antitoxin,  discovered  by  Behring  in  1890, 
we  have  a  specific  remedy  that  can  be  relied  upon  to  exert  a  curative 
influence  in  every  case  when  it  is  given  at  the  proper  time  and  in  the  proper 
dosage.  It  is  prepared  from  the  blood  serum  of  the  horse,  immunized  by 
gradually  increasing  doses  of  the  diphtheria  toxin.  The  horse  serum  thus 
obtained  contains  an  antitoxin  which  combines  with  and  neutralizes  the 
toxin  of  diphtheria,  and  quickly  brings  to  its  termination  the  localized 
inflammation  caused  by  the  diphtheria  bacillus.  This  specific  antitoxin 
came  into  more  or  less  general  use  in  1894,  following  an  exhaustive  in- 
vestigation by  M.  Roux  of  the  work  which  had  been  done  upon  this  subject 
up  to  that  time.  This  paper  was  so  convincing  that  antitoxin  was  at  once 
accepted  by  the  medical  world  as  a  specific  remedy  for  diphtheria.  From  that 
day  to  the  present  time  it  has  been  in  general  use  and  as  a  result  the  mor- 
tality from  diphtheria  throughout  the  world  has  been  enormously  diminislied. 
The  testimony  wherever  this  remedy  has  been  systematically  and  intelligently 
used  is  so  absolutely  convincing  as  to  its  specificity  that  it  is  difficult  to  un- 
derstand at  the  present  day  how  there  can  be  any  opposition  to  its  use. 


TREATMENT  303 

The  following  chart  from  McCollom  graphically  illustrates  the  value 
of  antitoxin  in  decreasing  the  death  rate  of  diphtheria : 


DIPHTHERIA- 

INTUBATION- 

-- 

-- 

-- 

- 

PERCENT 

OF 

MORTAUTY 

NO  ANTITOXIN 

ANTITOXIN                               1 

188S 

1889 

1890 

1891 

1893 

1893 

189J 

1893 

1896 

1897 

1898 

1899 

1900 

1901 

10O-2 

1903 

1004 

85.00 

80.00 
75.00 
70.00 
65.00 
60.00 
55.00 
50.00 
45  JX) 
40.00 
35.00 
30.00 
25.00 

ao.oo 

15.00 

10.00 
5.00 

••■i 

,»'' 

y^- 

—^' 

V- 

\ 

••' 

I 
\ 

1 

\ 

A 

Vi 

\ 

A 

4 

'\ 

-. 

-^ 

/ 

y^ 

A 

\ 

\ 

\        t 

/ 

\ 

V 

\ 

V 

\ 

\ 

\ 

i- 

— «^. 

..^. 

--^ 

.» 

\ 

VI 

I 

\_ 

I— 

"-^ 

^^ 

,^ 

"V^ 

"^w- 

Fig.  50. — Per  Cent,  of  Mortality  of  Diphtheria  at  the  Boston  City  Hospital,  Proper, 
AND  at  the  South  Department  from  1888  to  1904,  Inclusive.  Per  Cent,  of  Mor- 
tality OF  Intubations  for  the  Same  Time.  1888  to  1894  no  Antitoxin.  1895  to 
1904  Antitoxin.     (McCollom.) 

Antitoxin  should  be  given  by  subcutaneous  injection  in  the  loose  tissue 
of  the  back  beloM'  the  angle  of  the  scapula,  or  in  the  buttocks.  The  skin 
should  be  carefully  scrubbed  and  disinfected,  and  the  injection  made  with 
a  sterilized  syringe.  At  the  present  time  the  various  manufacturers  furnish 
antitoxin  in  sterile  syringes  ready  for  use.  In  uncomplicated  tonsillar  or 
pharyngeal  diphtheria  the  initial  dose  should  be  4,000  units,  except  in  in- 
fants under  one  year  of  age,  to  whom  2,000  or  3,000  units  should  be  given. 
If  the  symptom  group  be  not  greatly  improved,  a  second  dose  should  be 
given  eight  hours  later.  In  neglected  cases,  coming  into  the  hands  of  the 
physician  on  the  third  or  fourth  day  of  the  disease,  the  treatment  should  be 
begun  with  10,000  units,  and  this  dose  repeated  in  eight  hours,  if  no  im- 
provement is  noted.  In  laryngeal  diphtheria  the  initial  dose  should  be 
10,000  units,  and  if  the  laryngeal  stenosis  be  not  relieved,  from  40,000  to 
50,000  units  should  be  administered  within  the  next  three  days.  After  a 
large  experience  with  this  class  of  cases,  in  the  wards  of  a  city  hospital,  I 
am  convinced  that  the  mortality  in  laryngeal  diphtheria  would  be  less  and 
the  number  of  operative  cases  fewer  if  they  were  treated  with  large  doses. 
In  diphtheria  of  the  eye  large  doses  of  antitoxin  are  necessary  to  save  the 
21 


304  DIPHTHERIA 

eye;  10,000  units  should  be  given  every  six  hours  until  the  purulent  con- 
junctivitis is  controlled.  To  a  child  three  years  of  age  I  recently  gave 
70,000  units  over  a  period  of  four  days,  with  the  result  that  the  eye  was 
saved  and  no  untoward  symptoms  followed  the  antitoxin.  The  local  treat- 
ment should  be  directed  by  an  oculist;  it  consists  in  ice-cold  applications, 
the  frequent  irrigation  of  the  eye  with  a  3  per  cent,  boracic  acid  solu- 
tion, and  the  dilatation  of  the  pupil  with  atropin.  If  only  one  eye  is 
affected,  the  other  should  be  covered  with  a  watch  glass  and  carefully  sealed 
with  adhesive  plaster  and  collodion  to  prevent  its  infection. 

In  advocating  large  and  frequent  doses  of  antitoxin  in  the  cases  of 
diphtheria  which  threaten  life  or  endanger  the  eye,  I  do  not  wish  to  con- 
vey the  impression  that  these  large  doses  are  necessary  in  the  simpler  forms 
of  diphtheria  seen  in  private  practice.  As  previously  noted,  most  of  these 
cases  recover  promptly  under  from  4,000  to  8,000  units  of  antitoxin,  and 
the  giving  of  enormous  doses  unnecessarily,  while  it  may  do  no  harm, 
entails  an  expense  which  prejudices  the  public  against  the  use  of  this  most 
valuable  of  all  remedies.  The  only  unpleasant  results  that  I  have  ever 
seen  from  antitoxin  are  the  skin  rashes  which  so  commonly  follow  its  use, 
and  the  size  of  the  dose  has  little  to  do  with  the  appearance  of  these  rashes. 
Certain  anaphylactic  phenomena  may  occur  as  annoying  sequels  of  the 
antitoxin  treatment;  the  most  common  of  these  is  urticaria;  more  rarely 
a  rash,  morbilliform  or  scarlatinaform  in  character,  may  appear,  which  in 
connection  with  the  sore  throat  may  suggest  scarlet  fever;  arthralgia  and 
enterocolitis  are  occasionally  seen.  It  is  believed  that,  in  children  of 
asthmatic  constitution,  dangerous  and  even  fatal  anaphylactic  phenomena 
may  occur.    I  have  never  seen  such  a  case. 

Local  Treatment. — Before  the  days  of  antitoxin  the  life  of  the  child 
often  depended  upon  the  thoroughness  with  which  the  throat  and  nose 
were  cleansed  with  antiseptic  sprays,  gargles  and  douches.  The  throat 
and  pharynx  should  be  swabbed  alternately  with  a  1:1000  bichlorid  of  mer- 
cury and  20  per  cent,  argyrol  solutions  in  the  bad  cases  of  nasal  and 
pharyngeal  diphtheria  in  which  the  septic  cocci  are  playing  an  important 
role  in  producing  symptoms.  Where  the  lymphatic  glands  of  the  neck  are 
acutely  inflamed  an  ice-bag  is  the  best  application.  If  this  enlargement 
continues  for  a  number  of  days  poultices  may  be  substituted  for  the  ice 
and,  if  suppuration  occurs,  the  abscess  is  to  be  opened. 

In  laryngeal  diphtheria  steam  inhalations  are  of  some  value,  and  com- 
bined with  this,  calomel  may  be  sublimed.  The  croup  kettle  and  calomel 
sublimations,  however,  which  were  such  important  parts  of  the  treatment 
before  the  days  of  antitoxin,  are  now  but  rarely  used.  They  have  a  certain 
degree  of  efficacy  which  should  justify  their  remaining  a  part  of  the  treat- 
ment of  laryngeal  diphtheria;  however,  when  the  pseudo-membrane  pro- 
duces such  stenosis  of  the  larynx  that  the  child  is  becoming  exhausted  in 
its  efforts  to  force  air  into  the  lungs,  this  stenosis  must  be  relieved  either 
by  tracheotomy  or  intubation,  but  following  either  of  these  operations  the 
antitoxin  treatment  is  to  be  continued.    Of  these  two  operations  intubation 


TREATMENT  305 

is  universally  recognized  to  be  the  best.  It  has  many  advantages  over 
tracheotomy,  it  is  bloodless  and  therefore  not  objected  to  by  the  parents,  it 
is  quickly  accomplished  and  serves  the  purpose  of  relieving  the  stenosis, 
and  is  less  likely  to  be  followed  by  bronchopneumonia  than  is  tracheotomy. 
On  the  other  hand,  intubation  cases  require  more  careful  watching;  for 
this  reason,  in  remote  country  districts,  where  the  patient  cannot  be 
under  constant  supervision,  tracheotomy  is  to  be  preferred.  It  is  also  to 
be  used  where  intubation  fails  to  relieve  the  stenosis,  or  when  the  tube  is 
frequently  coughed  up. 

Intubation. — Dr.  Joseph  O'Dwyer,  of  New  York,  in  1883  perfected 
intubation,  and  the  intubation  set  which  he  devised  remains  to-day,  with 
unimportant  modifications,  in  general  use.  The  O'Dwyer  intubation  set 
consists  of  seven  tubes  made  of  vulcanized  rubber  on  a  metal  frame;  a 
gauge  for  determining  the  size  of  the  tube  suitable  to  the  age  of  the  pa- 
tient; obturators  and  a  handle  for  manipulating  the  tubes  in  their  intro- 
duction; an  extractor  for  removing  the  tubes  from  the  larynx,  and  a  gag 
for  holding  the  mouth  open  during  the  operation.  The  patient  is  wrapped 
in  a  blanket  with  his  arms  at  his  sides  and  held  firmly,  sitting  upright  in 
the  lap  of  the  nurse,  or  placed  on  a  table  in  a  horizontal  position  with  the 
head  thrown  backward;  the  recumbent  position  is  to  be  preferred.  The 
jaws  are  widely  separated  by  the  introduction  of  the  mouth  gag,  which 
is  held  firmly  in  position  by  an  assistant.  The  introducer,  with  tube  at- 
tached, is  held  in  the  right  hand,  and  the  forefinger  of  the  left  hand  is  in- 
troduced into  the  mouth  and  directed  downward  over  the  tongue  until  the 
epiglottis  is  felt.  This  is  hooked  forward  and  the  finger  inserted  into  the 
chink  of  the  glottis.  With  the  tip  of  the  finger  in  this  position  the  tube 
is  inserted  into  the  mouth,  following  the  line  of  the  finger,  being  careful 
to  keep  it  in  the  median  line  until  it  reaches  the  chink  of  the  glottis.  As 
it  enters  the  larynx  the  introducer  is  removed  and  the  tube  pushed  into 
position  by  the  left  index  finger.  If  the  tube  is  in  proper  position  the 
symptoms  of  stenosis  are  promptly  relieved.  If  the  operation  has  been 
unsuccessful,  the  tube  may  be  withdrawn  by  the  thread  to  which  it  was 
attached  before  its  introduction,  and  the  process  repeated  until  successful 
intubation  is  accomplished.  An  anesthetic  is  unnecessary  in  this  operation. 
After  a  variable  period  of  from  one  to  six  days,  when  the  disease  has  come 
under  the  control  of  antitoxin,  the  tube  should  be  removed.  This  operation 
is  more  difficult  than  inserting  the  tube.  The  index  finger  of  the  left  hand 
is  introduced  as  before  until  it  reaches  the  head  of  the  intubation  tube. 
With  this  finger  as  a  guide  the  extractor  is  inserted  and  the  tube  with- 
drawn.   If  the  stenosis  returns  the  tube  is  to  be  again  inserted. 

In  skilful  hands,  intubation  is  a  comparatively  simple  operation 
which  can  be  performed  with  little  danger  to  the  patient.  Where  the 
pseudo-membrane  is  extensive  the  tube  may  push  the  membrane  before  it 
into  the  trachea,  causing  obstruction,  which  is  commonly  relieved  by  a  vio- 
lent fit  of  coughing  and  the  expulsion  of  the  detached  membrane.  If 
suffocation  threatens,  tracheotomy  may  be  necessary  to  save  the  life  of  the 


306 


DIPHTHERIA 


child.  The  high  operation  above  the  isthmus  of  the  thyroid  is  to  be  pre- 
ferred, since  it  is  less  difficult  and  is  attended  with  less  bleeding;  occa- 
sionally the  low  operation  may  be  necessary.  Following  intubation,  care 
must  be  exercised  in  feeding  to  prevent  the  passage  of  food  material 
through  the  tube  into  the  bronchi;  this  accident  produces  violent  fits  of 
coughing.  It  was  formerly  believed  that  food  entering  in  this  way  was 
a  common  cause  of  pneumonia,  but  the  carefully  devised  experiments  of 
Northrup  have  shown  that  there  is  little  or  no  danger  from  "food  pneu- 
monia."   In  a  few  cases  it  may  be  necessary  in  giving  fluids  to  place  the 


Fig.  51. — Intubation  Position. 


child  upon  its  back  with  its  head  thrown  backward  over  the  side  of  the 
bed,  so  that  the  pharynx  is  lower  than  the  larynx.  In  very  rare  instances 
it  may  be  necessary  to  introduce  food  through  a  stomach  tube.  Bromid 
of  potash  combined  with  belladonna  in  some  palatable  vehicle  may  be  of 
value  in  relieving  the  cough  and  irritation  of  laryngeal  cases  in  which  a 
tube  has  been  inserted. 

General  Treatment. —  The  child  is  confined  to  bed  even  in  the  mild- 
est cases  because  of  the  danger  of  cardiac  paralysis.  Absolute  quiet  should 
be  insisted  upon  until  convalescence  is  fully  established.  The  patient 
throughout  his  illness  should  have  fresh  air  night  and  day,  and  be  placed 
under  the  best  hygienic  conditions  possible.    Throughout  the  treatment  the 


TEEATMENT  307 

diet  should  be  largely  milk.  Ice-cream  is  especially  grateful  to  many  of 
these  cases,  and  it  may  be  given  freely.  Cereals  may  also  be  allowed. 
From  tlie  beginning,  albuminous  foods,  however,  such  as  meat  and  eggs, 
should  be  dispensed  with  until  convalescence  is  established.  In  severe  and 
neglected  cases  whiskey  and  brandy  should  be  given  in  good-sized  doses, 
well  diluted — a  teaspoonful  every  tw^o  or  three  hours  for  a  child  three  or 
four  years  of  age.  In  these  cases  also  stimulation  may  be  necessary. 
Strychnin,  caffein  sodium  benzoate,  strophanthus,  digitalis  and  normal  salt 
solution  may  be  given  as  indicated  to  sustain  the  pulse,  overcome  exhaus- 
tion and  prevent  collapse.  In  more  desperate  cases  camphor  and  ether 
may  be  used  hypodermically. 

Treatment  of  Complications. — In  the  treatment  of  splanchnic  par- 
alysis previously  referred  to,  Forchheimer  says:  "My  remedies  for  vaso- 
constriction are  adrenalin  and  caffein,  administered  hypodermically.  Ad- 
renalin especially  possesses  the  property  of  producing  contraction  in  the 
blood  vessels  supplied  by  the  splanchnic  nerve;  as  its  effects  are  transitory, 
it  must  be  administered  frequently — every  two  to  three  hours  in  the  1 : 1,000 
solution,  of  which  from  1  to  1.5  c.  c.  are  given  at  a  dose.  Caffein  sodio- 
salicylate  may  be  given,  combined  with  adrenalin  or  alone;  when  the  pa- 
tient begins  to  improve,  caffein  alone  is  given  (v.  Chronic  Myocardial  In- 
sufficiency), the  adrenalin  being  gradually  discontinued,  because  I  have 
found  that  the  action  of  caffein  is  more  lasting  than  that  of  adrenalin. 
Further,  I  apply  two  or  three  ice-bags  to  the  abdomen,  to  act  upon  the 
abdominal  reflex,  because  this  increases  blood  pressure  and  reduces  fre- 
quency of  systole." 

Septicemia  becomes  a  part  of  the  pathological  process  in  untreated  cases 
by  the  third  or  fourth  day.  These  cases  should  therefore  be  treated  not 
only  for  diphtheria,  but  also  for  septicemia.  If  they  do  not  yield  readily 
to  large  doses  of  diphtheria  antitoxin,  then  anti-streptococcic  serum  and 
inunctions  of  unguentum  Crede  should  be  given  (see  Scarlet  Fever).  The 
latter  is  especially  indicated  in  severe  inflammation  of  the  lymphatic  glands 
of  the  neck. 

Bronchopneumonia  is  to  be  treated  as  outlined  under  the  treatment 
of  this  disease,  except  that  the  onset  of  a  pneumonia  complicating  diph- 
theria is  an  urgent  indication  for  large  and  repeated  doses  of  antitoxin. 
The  pneumonia  in  these  cases  is  caused  by  the  extension  of  the  pseudo- 
membrane  into  the  smaller  bronchi,  and  any  treatment  other  than  antitoxin 
is  of  little  avail. 

rost-diphtheritic  Paralysis. — This  is  to  be  treated  by  large  and  re- 
peated doses  of  diphtheria  antitoxin.  Comby  has  clearly  demonstrated  the 
value  of  this  remedy  in  the  cure  of  diphtheritic  neuritis.  From  3,000  to 
4,000  units  of  antitoxin  should  be  given  daily  over  a  period  of  eight  or 
ten  days.  While  antitoxin  greatly  shortens  the  duration  of  the  post-diph- 
theritic paralysis,  it  should  be  remembered  that  in  nearly  every  instance, 
even  in  the  absence  of  this  treatment,  time  restores  the  function  of  the 
nerve  and  cures  the  paralysis.    In  addition  to  the  specific  treatment  with 


308  INFLUENZA 

antitoxin  post-diphtheritic  paralysis  is  to  be  treated  as  outlined  in  the  chap- 
ter on  Neuritis.  Good  food,  fresh  air  and  proper  hygiene  are  important, 
and  following  the  acute  symptoms  general  massage  and  electricity  are  of 
advantage. 

CHAPTER    XXXVIII 
INFLUENZA 

Influenza  is  an  acute  infectious  and  highly  contagious  disease  caused 
by  the  influenza  bacillus.  It  is  characterized  by  fever  and  acute  catarrhal 
processes,  especially  of  the  respiratory  passages. 

Etiology. — The  influenza  bacillus,  discovered  by  Pfeiffer  in  1892,  is  the 
exciting  cause.  The  bacillus  septus,  the  pneumococcus,  the  micrococcus 
catarrhalis,  the  pyogenic  cocci  and  other  microorganisms  may  produce 
symptom  groups  characterized  by  catarrh  of  the  respiratory  passages  which 
cannot  easily  be  differentiated  from  influenza.  These  cases  are  spoken  of 
as  common  colds  or  epidemic  coryzas  and  are  to  be  treated  in  the  same 
manner  as  true  influenza. 

The  Pfeiffer  bacillus  is  found  in  great  numbers  and  almost  in  pure 
culture  in  the  mucous  discharges  from  the  nose,  throat  and  bronchi  in  the 
early  stages  of  influenza;  later  it  is  associated  with  streptococci,  staphy- 
lococci and  pneUmococci,  which  are  found  not  only  free  but  within  the  pus 
cells.  It  is  also  commonly  found  in  catarrhal  discharges  from  the  respira- 
tory passages  where  there  is  an  entire  absence  of  ordinary  acute  influenza 
symptoms;  such  cases,  it  is  believed,  represent  a  localized  chronic  phase 
of  this  disease,  and  are  associated  with  inflammation  of  adenoids,  bron- 
chitis or  apex  catarrh  of  the  lungs.  Influenza  bacilli  are  also  associated 
with  pyogenic  organisms  in  chronic  pus  forming  processes  such  as  otitis 
media  and  infections  of  the  sinuses  of  the  face.  The  Pfeiffer  bacillus 
rarely  produces  infection  in  lower  animals.  Inoculation  experiments  have 
for  the  most  part  resulted  in  failure. 

The  specific  cause  of  this  disease  is  commonly  spread  by  coughing, 
sneezing  and  expectorating.  The  danger  lies  not  only  in  the  moist  bacilli 
thus  discharged,  but  in  the  dried  bacilli  which  may  contaminate  public  con- 
veyances, homes,  schools  and  other  places  where  people  are  gathered  to- 
gether indoors.  Influenza  bacilli  are  so  readily  disseminated  both  in  the 
dry  and  in  the  moist  state  that  the  disease  is  highly  contagious  and  spreads 
rapidly  through  households,  schools  and  communities  in  epidemic  form. 
A  number  of  pandemics  of  this  disease  have  occurred;  the  last  one  in 
1889,  when  30  or  40  per  cent,  of  the  entire  population  of  our  large  cities 
suffered  more  or  less  from  it.  Since  that  time  the  disease  has  been  present 
to  a  greater  or  less  extent  in  all  of  our  large  cities,  so  that  occasional 
cases  may  occur  throughout  the  year.  The  influence  of  climate  in  favor- 
ing its  spread  is  shown  by  the  fact  that  it  becomes  epidemic  during  the 
winter  months,  beginning  usually  before  the  first  of  January,  reaching  a 


SYMPTOMATOLOGY  309 

maximum  in  Februar}-,  and  gradually  subsiding  in  the  early  spring.  One 
of  the  noticeable  features  of  these  epidemics  is  house  infections,  the  disease 
persisting  throughout  the  winter  and  early  spring  in  certain  houses.  The 
children  living  therein  suffer  during  this  time  from  frequent  recurring  at- 
tacks of  mild  influenza,  which  are  probably  due  to  reinfection.  In  other 
instances  these  repeated  attacks  may  be  due  to  relapsing  or  chronic  in- 
fluenza, the  Pfeiffer  bacillus  never  entirely  disappearing  from  the  adenoids, 
tonsils,  sinuses  and  other  of  their  favorite  hiding  places. 

Nursing  infants  under  six  months  of  age  are  practically  immune,  and 
the  disease  is  comparatively  infrequent  during  the  second  six  months  of 
life.  It  may,  in  rare  instances,  occur  even  in  the  new-born.  After  the 
first  year  susceptibility  to  this  disease  rapidly  increases,  so  that  children 
three  or  four  years  of  age  are  almost,  if  not  quite,  as  susceptible  as  adults. 
It  is  common  even  in  old  age.  At  the  two  extremes  of  life  the  disease,  by 
reason  of  its  complications,  is  more  dangerous. 

Pathology. — The  pathological  changes  which  properly  belong  to  in- 
fluenza are  those  of  a  catarrhal  inflammation  of  the  mucous  membrane  of 
the  respiratory  passages.  The  accessory  sinuses  are  not  infrequently  in- 
volved and  the  tonsils,  adenoids  and  neighboring  lymphatic  glands  are 
enlarged  by  congestion  or  inflammation.  The  mucous  membrane  of  the 
intestine  may  be  acutely  inflamed,  and  almost  every  organ  and  tissue  of 
the  body  may  be  either  directly  or  indirectly  injured  by  the  Pfeiffer 
bacillus  and  the  pyogenic  organisms  which  are  so  commonly  associated 
with  it  in  its  destructive  processes. 

Incubation. — The  average  period  of  incubation  is  from  two  to  three 
days,  but  it  is  commonly  believed  that  this  period  may  vary  from  twelve 
hours  to  a  week. 

Symptomatology. — The  symptom  group  presented  by  influenza  is  very 
variable,  and  different  epidemics  may  be  characterized  by  the  predominance 
of  a  certain  set  of  clinical  symptoms,  which  in  another  epidemic  may  be 
largely  in  abeyance.  The  most  characteristic  symptom  group,  however,  is 
that  produced  by  catarrhal  inflammation  of  the  respiratory  passages. 

Onset. — The  temperature  rises  rapidly,  in  some  instances  reaching 
105°r.  within  the  first  twenty-four  hours;  the  younger  the  child  the 
higher  and  the  more  rapid  the  rise  of  the  temperature;  there  may  be  a 
sensation  of  chilliness  or  even  a  decided  rigor;  in  infants  convulsions  may 
occur.  The  discomfort  of  this  period  is  very  acute,  the  head,  back,  and 
every  part  of  the  body  may  ache,  and  there  is  usually  complete  loss  of 
appetite  with  more  or  less  gastric  disturbance.  The  prostration  is  marked, 
quite  out  of  proportion  to  the  other  symptoms,  and  the  child  presents  the 
appearance  of  being  very  ill.  The  younger  the  child  the  more  pronounced 
are  these  general  symptoms.  The  fever  may  begin  to  fall  within  thirty-six 
hours,  but  commonly  does  not  reach  normal  until  the  third  or  fourth  day. 
It  may,  however,  be  prolonged  by  various  complications.  In  subacute  or 
chronic  forms  of  the  disease  the  temperature  after  reaching  normal  may 
slowly  rise  again,  and  a  slight  and  variable  fever  may  last  for  weeks. 


310  INFLUENZA 

Coryza,  which  is  one  of  the  most  characteristic  symptoms,  may  occur 
early  in  the  disease,  but  is  usually  delayed  until  the  second  day.  Tonsil- 
litis and  pharyngitis  as  a  rule  precede  the  coryza.  The  pharynx  is  markedly 
congested,  the  tonsils  enlarged,  and  not  infrequently  a  complicating  infec- 
tion produces  a  white  exudate.  These  symptoms  are  usually  followed 
by  bronchitis  or  laryngitis,  which  give  rise  to  an  irritating  cough  which 
may  be  hoarse  and  paroxysmal  in  character,  in  some  instances  resembling 
the  whooping-cough  paroxysm. 

Nervous  Symptoms. — In  young  children  the  disease  may  commence 
with  vomiting,  stupor  and  symptoms  of  meningeal  irritation,  closely  re- 
sembling a  beginning  meningitis.  This  profound  toxemia,  involving  the 
nerve  centers,  while  not  so  common,  may  occur  in  older  children.  Head- 
ache and  extreme  nervous  irritability  are  common  symptoms,  and  in  older 
children  neuralgic  pain  is  a  very  common  occurrence.  Almost  any  nerve 
in  the  body  may  be  affected,  but  the  supraorbital  is  most  commonly  so. 
Severe  intermittent  supra-  or  infraorbital  neuralgia,  persisting  after  the 
acute  symptoms  have  subsided,  is  strongly  suggestive  of  sinus  infection. 

Acute  gastroenteritis  is  very  frequently  caused  by  influenza;  this 
manifestation  is  usually  spoken  of  as  intestinal  grippe.  It  commonly 
follows,  but  it  may  occur  quite  independently  of  the  catarrhal  symptoms 
on  the  part  of  the  respiratory  tract.  It  is  much  more  frequent  in  young 
than  in  older  children,  because  at  this  age  the  bronchial  mucus  carrying 
infection  is  swallowed  and  the  intestinal  mucous  membrane  is  perhaps  less 
resistant.  With  the  onset  of  this  condition  there  may  be  nausea,  vomiting, 
increase  of  fever  and  a  sharp  diarrhea.  The  discharges  are  putrid  and 
contain  large  quantities  of  mucus  which  may  be  tinged  with  blood.  The 
symptoms  of  an  ordinary  acute  enterocolitis  may  follow,  last  for  weeks, 
and  place  the  patient's  life  in  jeopardy;  especially  is  this  true  in  infancy. 
These  cases  occurring  in  older  children  may  resemble  typhoid  fever. 

An  erythematous  rash  is  frequently  present  during  the  acute  stages  of 
influenza.  It  may  be  very  slight  or  it  may  be  very  marked,  covering  almost 
the  entire  body,  presenting  an  exanthem  very  like  that  of  scarlet  fever;  it 
commonly  disappears  within  twenty-four  or  thirty-six  hours.  Other  skin 
eruptions  may  appear,  such  as  urticaria  and  a  roseola  somewhat  similar 
to  the  rash  of  measles;  these  eruptions  are  all  evanescent,  and  therefore 
do  not  commonly  embarrass  the  diagnosis  for  more  than  twelve  or  twenty- 
four  hours. 

Blood. — Lord  and  other  observers  have  found  a  slight  leukocytosis  in 
this  disease,  which  becomes  more  marked  when  the  influenza  is  compli- 
cated by  septic  processes,  or  when  a  more  or  less  latent  glandular  tuber- 
culosis has  been  rendered  active  by  an  attack  of  influenza. 

The  clinical  picture  of  influenza  above  given  may  be  greatly  varied  by 
the  absence  of  certain  symptom  groups.  In  some  instances  the  catarrhal 
symptoms  on  the  part  of  the  nose,  throat  and  upper  air  passages  may  be 
very  marked  and  very  persistent,  with  slight  fever  and  no  nervous  or  other 
constitutional  symptoms.     In  other  cases  the  catarrhal  symptoms  of  the 


COMPLICATIONS  311 

respiratory  tract  may  be  entirely  absent,  the  fever  and  nervous  symptoms 
predominating  and  producing  a  clinical  picture  quite  unlike  that  of  ordi- 
nary influenza.  In  other  instances,  especially  in  young  children,  gastro- 
enteric infection  followed  by  an  enterocolitis  may  occur  without  preliminary 
catarrhal  symptoms  on  the  part  of  the  respiratory  tract.  That  is  to  say, 
this  disease  may  present  itself  in  three  well-marked  symptom  groups:  the 
first  and  most  characteristic  is  produced  by  catarrh  of  the  respiratory 
passages;  the  second  by  the  systemic  intoxication;  the  third  by  gastro- 
enteric infection.  The  clinical  picture  may  present  a  combination  of  these 
three  groups,  any  one  of  which  may  predominate,  or  may  be  absent. 

In  infants  and  very  young  children  the  clinical  syndrome  of  acute 
influenza  may  present  certain  peculiarities.  The  general  infection  is  more 
severe  and  more  sudden  in  its  onset.  Vomiting,  convulsions,  lack  of  appe- 
tite, apathy,  stupor,  opisthotonos  and  other  symptoms  closely  simulating  a 
beginning  meningitis  may  occur.  The  fever  is  higher  and  rises  more  sud- 
denly. Gastrointestinal  infection  with  resulting  catarrh  is  much  more 
frequent.  The  erythematous  exanthem  is  more  frequently  seen.  The 
catarrhal  symptoms  appear  later.  The  coryza  is  not  generally  so  marked. 
The  bronchitis  which  occurs  late  is  much  more  serious  than  in  older  chil- 
dren, and  pneumonia  is  more  common. 

Chronic  Influenza. — The  course  of  an  uncomplicated  influenza 
varies  from  three  days  to  two  weeks,  and  within  this  time  the  patient 
should  and  commonly  does  entirely  recover.  A  few  cases,  however,  by  rea- 
son of  the  fact  that  they  have  influenza  bacilli  concealed  in  their  tonsils, 
adenoids  or  some  of  the  accessory  sinuses  of  the  nasopharynx,  suffer  from 
repeated  mild  relapses  of  attacks,  the  disease  in  this  way  becoming  chronic. 
These  cases  frequently  have  enlarged  and  diseased  adenoids  or  tonsils ;  they 
Buffer  from  a  low  fever  which  may,  for  a  few  days  at  a  time,  reach  normal 
or  even  fall  below  normal,  to  be  followed  again  by  a  slight  rise  of  tempera- 
ture, rarely  above  102°F.  These  acute  exacerbations  of  fever  may  be  asso- 
ciated with  headache  and  general  discomfort  and  in  older  children  periodic 
neuralgias  may  occur.  The  patient  fails  to  regain  his  appetite,  is  weak, 
anemic,  and  loses  in  weight  and  strength.  The  catarrhal  symptoms  on 
the  part  of  the  respiratory  mucous  membrane  are  more  or  less  prominent; 
a  spasmodic  cough,  resembling  whooping-cough,  may  continue  for  weeks, 
but  differs  from  the  whooping-cough  paroxysm  in  that  it  is  less  violent,  is 
not  aggravated  at  night  and  is  not  usually  accompanied  by  the  whoop  or 
followed  by  vomiting.  The  rhinitis,  while  not  very  acute,  is  commonly 
present  to  a  greater  or  less  degree. 

Immunity. — One  attack  does  not  confer  immunity  for  any  great  period 
of  time,  but  it  does  offer  a  degree  of  temporary  protection.  It  is  a  mat- 
ter of  clinical  record  that  influenza  has  appeared  in  a  milder  form  since 
the  great  epidemics  of  1889  and  1891 ;  this  is  perhaps  due  to  the  fact  that 
a  great  percentage  of  the  population  have,  from  previous  attacks,  acquired 
a  certain  degree  of  immunity. 

Complications. — Otitis  media  is  such  a  common  complication  that  the 


312  INFLUEXZA 

ear  driinis  should  be  examined  in  every  case.  In  this  condition  the  influ- 
enza bacilli  are  associated  with  septic  organisms  and  may  produce,  a 
mastoiditis.  The  frontal  and  ethmoidal  sinuses  may  be  affected,  especially 
in  older  children.  Albuminuria  occurs  very  commonly  in  children  suf- 
fering from  influenza.  Acute  hemorrhagic  nephritis  may  develop  very 
suddenly  during  the  height  of  the  disease;  these  cases  not  infrequently 
have  a  fatal  termination.  Post-grippe  nephritis  is  less  violent  and  runs 
a  much  more  benign  course  than  the  hemorrhagic  form.  I  believe 
that  a  large  percentage  of  the  cases  of  so-called  idiopathic  nephritis  as 
well  as  those  supposed  to  be  produced  by  exposure  to  "cold/"'  are  cases 
of  influenzal  nephritis,  having  their  origin  in  a  recent  attack  of  this  disease ; 
1  also  believe  that  influenza  is  one  of  the  most  common  causes  of  chronic 
nephritis,  and  I  feel  quite  sure  that  our  text  books  and  medical  literature 
have  not  given  to  this  subject  the  prominence  it  deserves.  Tuberculosis 
is  one  of  the  most  serious  and  common  complications;  an  attack  of  in- 
fluenza may  aggravate  an  existing  pulmonary  or  lymph-node  tuberculosis. 
A  prolonged  bronchopneumonia  with  migrating  areas  of  consolidation 
may  be  produced  by  the  influenza  bacillus.  Conjunctivitis  and  other  in- 
flammatory conditions  of  the  eye  may  occur.  The  heart  may  be  over- 
whelmed by  the  toxemia,  much  as  it  is  in  diphtheria,  and  a  myocardial 
weakness  may  persist  for  months  after  the  acute  symptoms  of  the  disease 
have  disappeared.    In  rare  instances  a  splanchnic  paralysis  may  occur. 

Diagnosis. — It  is  practically  impossible  to  differentiate  mild  cases  of 
influenza  from  other  catarrhal  conditions  of  the  respiratory  passages.  The 
pneumococcus,  the  micrococcus  catarrhalis,  and  other  microorganisms  pro- 
duce similar  conditions  of  the  nose,  throat  and  bronchi,  which  can  only  be 
differentiated  by  an  early  bacteriological  examination.  In  private  prac- 
tice this  is  rarely  resorted  to,  as  the  differential  diagnosis  of  these  condi- 
tions from  a  clinical  standpoint  is  not  very  important,  since  we  have  no 
speciflc  treatment,  and  all  are  treated  alike  in  a  purely  symptomatic  way. 
From  tuberculosis,  influenza  can  be  differentiated  by  the  absence  of  the 
tuberculin  skin  reaction  and  by  the  failure  to  find  tubercle  bacilli  in  the 
sputum ;  from  meningitis,  by  an  examination  of  the  cerebrospinal  fluid  and 
by  the  subsequent  history  of  the  case;  from  typhoid  fever,  by  the  absence 
of  rose  spots,  the  Widal  reaction,  and  other  symptoms  of  typhoid. 

Prognosis. — The  prognosis  of  uncomplicated  influenza  is  almost  always 
good.  In  rare  instances  young  children  are  overwhelmed  by  the  toxemia 
and  death  may  result  from  cardiac  paralysis,  cerebral  congestion,  or  intes- 
tinal toxemia.  Apart  from  this  the  danger  lies  in  its  many  complications, 
such  as  bronchopneumonia,  acute  Bright's  disease,  and  mastoiditis,  which 
may  result  fatally. 

Prophylaxis. — Patients  suffering  from  acute  influenza  should  be  isolated 
from  other  members  of  the  household.  This  is  especially  important  dur- 
ing the  early  acute  catarrhal  stage,  as  this  is  the  period  of  greatest  in- 
fection. The  very  young,  the  old,  and  individuals  suffering  from  tubercu- 
losis and  other  chronic  diseases  should  be  protected  from  this  contagion, 


TREATMENT  313 

since  among  this  class  of  patients  the  disease  is  unusually  severe  and 
its  complications  especially  dangerous.  House  disinfection  is  a  most 
important  prophylactic  measure;  in  homes  that  are  infected  with  this 
contagion  the  disease  may  continue  to  recur  among  the  children  of  the 
family  from  time  to  time  throughout  the  winter  and  spring  months;  for- 
maldehyde disinfection  may  jirevent  these  reinfections.  Catarrhal  dis- 
charges from  the  respiratory  passages  should  be  destroyed.  Individual 
prophylaxis  is  also  of  importance.  Much  can  be  done  by  having  the  well 
children  of  the  family  spray  or  douche  their  noses  and  throats  once  a  day 
with  a  mild  alkaline  antiseptic.  They  should  also  spend  as  much  time  as 
possible  out  of  doors,  and  their  physical  condition  should  be  looked  to,  if 
necessary,  by  the  administration  of  cod-liver  oil,  iron  and  other  tonics. 
This  is  especially  important  in  families  having  a  tuberculous  family  history. 
Treatment. — The  patient  should  be  confined  to  bed  during  the  acute 
stage  of  the  disease.  Rest  in  bed  is  a  most  important  curative  measure. 
The  diet  should  be  simple,  suited  to  the  age  of  the  child,  and  especially 
selected  with  reference  to  throwing  little  work  upon  the  excretory  organs. 
Milk,  cereals,  bread  and  in  older  children  fruit  Juices  should  be  recom- 
mended. Albuminous  foods,  such  as  meats  and  eggs,  are  to  be  avoided 
during  the  acute  stage,  and  but  sparingly  allowed  during  early  convales- 
cence. The  patient  should  be  induced  to  drink  as  much  water  as  possible, 
as  this  helps  to  modify  the  febrile  symptoms  and  to  promote  the  excretion 
of  poisons.  A  lukewarm  tub  bath  once  or  twice  a  day  is  not  only  grateful, 
but  is  a  valuable  therapeutic  measure,  as  it  quiets  the  nervous  symptoms 
and  promotes  elimination.  The  medical  treatment  should  begin  with  a 
dose  of  calomel.  This  is  to  be  followed  by  a  mild  saline  cathartic  such  as 
phosphate  of  soda  or  Rochelle  salts,  and  throughout  the  course  of  the 
disease  mild  cathartic  medication  may  be  necessary.  Quinin  is  the  most 
valuable  remedy  in  the  treatment  of  influenza.  In  children  under  five 
years  of  age  from  1  to  4  grains  of  euquinin  may  be  given  every  three  or 
four  hours.  Quinin  in  this  form  can  usually  be  administered  without  pro- 
ducing gastric  disturbance;  if  discomfort  follows  its  use,  it  should  be  dis- 
continued. In  children  over  five  years  of  age  the  bisulphate  or  some  of 
the  other  preparations  of  quinin  may  be  given  in  pill  or  capsule,  or  com- 
bined with  chocolate  or  licorice  as  recommended  in  the  chapter  on  Malaria. 
Benzoate  of  soda  is  a  remedy  of  value  in  the  routine  treatment  of  influ- 
enza. It  should  be  given  every  four  hours  in  doses  of  from  1  to  5  grains, 
according  to  the  age  of  the  child.  It  may  be  advantageously  combined  with 
tincture  of  belladonna.  Phenacetin  is  a  drug  almost  universally  used  and 
almost  universally  abused  in  the  treatment  of  influenza.  It  is,  however,  of 
value  when  judiciously  given.  Of  all  the  coal-tar  products  it  is  perhaps 
the  least  objectionable.  It  may  be  given  to  modify  the  headache,  fever, 
and  distressing  symptoms  at  the  very  onset  of  the  disease,  but  should  not 
be  continued  longer  than  is  absolutely  necessary.  It  adds  very  materially 
to  the  comfort  of  the  patient  during  the  first  two  or  three  days,  but  exer- 
cises no  curative  influence  on  the  disease,  and  if  prolonged  it  may  increase 


314  INFLUENZA 

prostration  and  cardiac  weakness.  For  a  child  one  year  of  age,  1  grain 
may  be  given  every  three  or  four  hours,  increasing  the  dose  one-half  grain 
for  every  year  of  life  until  the  maximum  dose  of  3  grains  is  reached.  As- 
pirin is  a  remedy  of  perhaps  equal  value  with  phenacetin  and  may  be 
used  in  the  same  dosage.  Salol  is  especially  to  be  recommended  for  infants 
and  young  children  and  should  be  substituted  for  the  phenacetin  and  as- 
pirin in  those  cases  where  the  acute  discomfort  is  not  great  enough  to 
demand  the  use  of  these  drugs ;  it  may  be  given  in  twice  the  dosage  recom- 
mended for  phenacetin. 

Splanchnic  paralysis  and  cardiac  weakness  occurring  in  this  disease  are 
to  be  treated  as  recommended  in  the  chapter  on  Diphtheria. 

The  coryza  and  pharyngitis  may  be  treated  by  local  applications  of  mild 
antiseptics.  In  infants  and  young  children  10  minims  of  the  oil  of  eucalyp- 
tus may  be  combined  ^nth  1  ounce  of  liquid  albolin,  and  this  may  be 
dropped  into  the  nose  with  a  medicine  dropper  at  three  or  four-hour  in- 
tervals. For  older  children  2  grains  of  menthol  may  be  added  to  this 
prescription  and  this  applied  to  the  nose  and  throat  with  an  atomizer. 
Weak  alkaline  antiseptic  sprays  may  also  be  used  to  cleanse  and  disinfect 
the  mucous  membranes  of  the  throat  and  nasopharynx;  these  may  precede 
by  one  hour  the  albolin  spray  above  mentioned.  When  the  acute  symp- 
toms have  subsided  the  course  of  the  coryza  and  pharyngitis  can  be  greatly 
shortened  by  the  systematic  use  twice  a  day  of  these  local  applications. 

The  cough  which  accompanies  the  bronchitis  and  laryngitis  of  this 
disease  requires  treatment.  For  this  purpose  the  bromid  of  soda  and  tinc- 
ture of  belladonna,  put  up  with  glycerin  and  some  palatable  elixir,  may 
be  used.  For  a  child  three  years  of  age  4  grains  of  bromid  of  potash  and 
1  minim  of  tincture  of  belladonna  may  be  given  at  four-hour  intervals. 
Where  the  cough  is  very  irritable  and  harassing  heroin  or  codein  may 
be  combined  with  this  prescription.  Heroin  hydrochlorate  (1/150  grain) 
and  codein  sulphate  (1/40  grain)  may  be  given  to  a  child  five  years  of  age. 
It  is  advisable,  however,  to  avoid  opium  and  all  its  derivatives,  when  pos- 
sible, and  they  should  rarely  be  given  to  children  under  two  years  of  age. 
Acute  gastroenteric  infection  and  resulting  enteritis  are  to  be  treated  as 
directed  in  the  chapters  on  these  conditions. 

In  influenza  the  physician  should  bear  in  mind  that  we  have  no  specific 
treatment,  and  that  the  condition  is  a  self-limited  one,  which  has  a  tendency 
to  run  a  benign  course  even  if  no  medication  is  used.  The  medical  treat- 
ment, therefore,  should  be  as  simple  as  possible,  and  only  such  drugs  used 
as  are  especially  demanded  by  the  symptoms  present.  Chronic  influenza 
yields  most  readily  to  climatic  treatment.  These  cases  should  be  sent  to 
a  warm  and  equable  climate  where  the  patient  may  live  out  of  doors. 

After-treatment. — It  is  most  important  that  the  physician  should  be 
thoroughly  awake  to  the  fact  that  an  active  bronchial  lymph-node  tuber- 
culosis is  not  uncommonly  lighted  up  by  an  attack  of  influenza;  in  the 
after-treatment  of  these  cases  a  warm  equable  climate,  cod-liver  oil  and  iron 
are  most  important.     Many  cases  of  influenza,  in  which  there  is  no  trace 


ETIOLOGY  315 

of  tuberculosis,  are  left  in  an  anemic  and  weak  condition ;  they  are  also 
benefited  by  the  cod-liver  oil  and  iron  treatment.  In  children  who  have 
suffered  from  prolonged  attacks  of  influenza,  characterized  especially  by 
catarrhal  conditions  of  the  nasopharynx,  a  careful  examination  of  the  ton- 
sils and  adenoids  should  be  made,  and  if  these  tissues  be  diseased  or  en- 
larged they  should  be  removed;  this  is  a  most  important  curative  measure. 
In  many  instances,  in  children  suffering  from  recurring  attacks  of  catarrhal 
influenza,  I  have,  in  the  interval  between  these  acute  attacks,  when  the 
catarrhal  symptoms  were  more  or  less  in  abeyance,  had  the  tonsils  and 
adenoids  removed,  with  the  result  that  a  troublesome  cough  which  had  per- 
sisted for  months  would  disappear  and  other  catarrhal  symptoms  gradually 
subside. 


CHAPTER    XXXIX 

SCAELET-FEVEB 
(Scarlatina) 

Scarlatina  is  an  acute  infectious  and  very  contagious  disease,  character- 
ized by  fever,  sore  throat  and  a  punctate  scarlet  rash  which  may  cover  the 
entire  body  and  which  is  followed  by  widespread  desquamation  of  the 
superficial  epithelial  layers  of  the  skin. 

Etiology. — Predisposing  Causes. — Scarlet  fever  is  a  disease  of  child- 
hood ;  it  may,  however,  occur  at  any  period  of  life.  The  young  adult  grad- 
ually acquires  more  or  less  immunity,  so  that  in  middle  life  the  disease  is 
comparatively  rare,  and  much  less  severe,  often  manifesting  itself  as  a  mild 
attack  of  scarlatinal  angina.  It  is  also  very  rare  during  the  first  year 
of  life.  The  comparative  immunity  which  is  enjoyed  by  the  young  infant 
is  probably  due  to  immune  bodies  derived  from  placental  blood  and  is  kept 
up  to  a  degree  by  the  breast  milk.  McCollom  says  that  young  infants  are 
more  susceptible  than  children  of  any  other  age;  Heubner,  on  the  other 
hand,  never  saw  a  case  under  six  months  of  age.  The  explanation  of  these 
widely  differing  opinions  lies  in  the  probability  that  it  is  the  nursing  in- 
fant only  that  enjoys  this  comparative  immunity,  and  that  bottle-fed  in- 
fants, however  young  they  may  be,  are  perhaps  as  susceptible  to  this  disease 
as  older  children.  After  the  first  year  of  life  scarlet  fever  increases  in 
frequency  up  to  the  sixth  year;  the  largest  number  of  cases  occur  during 
the  sixth  and  seventh  years;  thereafter  the  disease  diminishes  until,  at 
sixteen,  it  is  rather  infrequent  and  later  becomes  comparatively  rare.  The 
susceptibility  of  the  individual  child  is  an  important  and  unexplained  fac- 
tor; only  about  one-half  of  the  children  at  the  most  susceptible  age  con- 
tract the  disease  even  when  they  are  brought  into  very  close  contact  with 
the  contagion.  Scarlet  fever  is  more  prevalent  during  the  winter  than 
the  summer  months.  The  influence  of  cold  weather  in  spreading  this 
disease  may  be  explained  by  the  fact  that  it  is  during  the  winter  months 


316  SCAKLET  FEVER 

that  children  are  housed  together  in  school-rooms  and  in  their  homes,  thus 
producing  conditions  which  favor  the  spread  of  contagious  diseases,  while 
during  the  summer  months  they  live  an  outdoor  life  and  are  altogether 
under  better  hygienic  surroundings.  Minor,  in  his  summary  of  the  geo- 
graphical disposition  of  scarlet  fever,  apparently  demonstrates  that  the 
disease  thrives  best  in  temperate  climates.  He  found  that  in  the  West- 
ern Hemisphere  scarlet  fever  occurred  between  the  10th  and  30th  degrees, 
X.  latitude,  and  that  above  and  below  this  were  zones  of  comparative  im- 
munity, in  which  the  disease  did  not  thrive  for  any  length  of  time,  even 
if  imported. 

Exciting  Causes. — A  microorganism,  as  yet  undiscovered,  is  the  cause 
of  scarlet  fever.  The  lower  animals  so  far  as  we  know  are  not  susceptible, 
and  we  have  no  evidence  that  the  scarlet  fever  germ  can  multiply  outside 
the  human  organism.  There  is  evidence,  however,  that  it  may  live  and  be 
transported  in  milk,  the  milk  acting  as  a  carrier  rather  than  as  a  culture 
medium.  The  specific  cause  of  scarlet  fever  is  very  tenacious  of  life,  and 
may  live  for  a  long  time  under  very  adverse  circumstances.  It  may  cling 
to  bedding,  carpeting,  hangings,  clothing,  linen,  to  the  wall-paper  and  to 
apparently  everything  with  which  it  comes  in  contact.  It  is  especially  diffi- 
cult to  eradicate  from  infected  rooms;  many  instances  are  on  record  where 
such  rooms  have  been  cleaned  and  apparently  disinfected,  and  yet  months 
later  the  disease  has  been  contracted  by  children  who  have  moved  into 
them.  The  contagion  of  this  disease  lies  especially  in  the  muco-pus  from 
the  nose,  throat,  ears  and  in  the  scales  of  epithelium  cast  off  by  the  der- 
matitis. The  air  immediately  surrounding  the  patient  is  apparently  not 
contaminated  for  more  than  four  or  five  feet,  and  this  contamination  prob- 
ably results  largely  from  the  spray  of  mucus  that  is  coughed  into  the  sur- 
rounding air.  Dried  mucus  and  fine  epithelial  scales  carrying  contagion 
may  be  swept  or  otherwise  thrown  into  the  air,  and  perhaps  be  wafted  for 
slight  distances.  Human  intercourse,  which  brings  the  well  in  contact 
with  the  sick,  is  the  great  cause  of  the  spread  of  this  disease.  In  older 
children  it  frequently  manifests  itself  as  a  scarlatinal  angina;  such  chil- 
dren may  never  be  seen  by  a  doctor,  and  may  continue  to  go  to  school,  or 
to  children's  parties,  or  to  mingle  freely  with  the  other  children  of  the 
household,  spreading  the  disease  in  their  wake;  this  is  perhaps  the  most 
common  way  in  which  the  disease  is  disseminated.  Children  that  are  sup- 
posed to  be  convalescent,  but  who  still  have  otitis  media,  rhinitis,  or  slight 
desquamation,  are  very  frequently  turned  loose  upon  the  community  while 
they  are  still  capable  of  spreading  the  infection.  The  poison  may  also  be 
carried  by  letters,  and  by  cats  and  dogs  which  pass  from  the  sick  to  the 
well.  Epidemics  are  also  reported  in  which  contaminated  milk  was  sup- 
posed to  be  the  carrier.  Attendants  and  nurses  may  spread  the  disease  in 
street -cars  and  homes  to  which  they  go  after  a  night  or  day  of  nursing. 
The  doctor,  if  he  takes  proper  precautions,  should  not  be  a  source  of  dan- 
ger. After  many  years  of  experience  in  hospital  and  private  practice,  I 
have  never  had  a  case  in  which  there  was  the  least  suspicion  that  I  had 


PATHOLOGY  317 

been  the  carrier  of  the  contagion.  The  infection  commonly  enters  through 
the  mouth  or  nose  and  affects  primarily  the  mucous  membrane  of  the  naso- 
pharynx. It  may,  however,  enter  surgical  or  other  wounds,  or  it  may,  by 
the  hand  of  the  obstetrician,  be  carried  into  the  vagina.  These  latter  meth- 
ods of  infection  are  now  very  rare. 

Period  of  Contagion.  — Scarlet  fever  is  contagious  from  the  appearance 
of  the  first  catarrhal  symptoms  in  the  throat.  The  most  contagious  period 
is  during  the  first  week,  when  the  fever  and  throat  symptoms  are  severe. 
Witli  the  subsidence  of  these  symptoms  the  disease  is  less  contagious,  but 
with  the  beginning  of  desquamation  it  again  becomes  more  contagious,  and 
contagion  probably  exists  as  long  as  desquamation  lasts,  or  as  long  as  there 
is  a  mucopurulent  discharge  from  the  nose,  ears,  and  throat.  In  all  well- 
marked  cases  it  is  safe  and  proper  to  assume  that  the  contagion  lasts  for  at 
least  six  weeks,  and  during  this  time  there  should  be  a  rigid  quarantine. 
The  proper  care  of  the  skin,  the  disinfection  of  the  throat  and  general 
liygionic  measures  for  destroying  the  contagion  and  preventing  the  40)n- 
tamination  of  the  surroundings  will  diminish  the  period  of  conta- 
giousness. 

Pathology. — The  specific  organism  of  scarlet  fever  is  unknown,  but 
streptococci  play  a  most  important  role  in  its  pathology.  These  cocci, 
which  are  almost  always  found  in  the  throat  and  often  in  the  blood,  have 
been  believed  by  many  writers  to  be  the  actual  cause  of  this  disease.  Klein 
and  Gordon  described  a  streptococcus  scarlatina  and  Kurth  a  streptococcus 
conglomeratus,  these  organisms  differing  slightly  from  the  streptococcus 
pyogenes  which  has  been  so  generally  associated  with  the  pathology  of 
scarlet  fever.  The  streptococci  which  have  been  found  in  the  throat  and 
blood  of  scarlet  fever  patients  have  no  well-defined  characteristics  which 
differentiate  them  from  other  streptococci.  The  streptococcus  pyogenes  and 
the  staphylococcus  aureus  and  albus  are  more  or  less  definitely  associated 
with  the  destructive  processes  which  accompany  and  follow  scarlet  fever. 
Hektoen  found  that  the  degree  of  streptococcemia  in  scarlet  fever  was 
closely  related  to  the  severity  of  the  disease.  In  mild  cases  few  streptococci 
were  found  in  the  blood ;  in  severe,  and  especially  in  complicated,  cases  they 
were  found  in  larger  numbers.  They  may,  however,  be  absent  from  the 
blood  in  even  fatal  cases.  Streptococci  are  also  found  in  the  urine  and  in 
the  discharges  from  the  nose,  throat,  and  ears.  Mallory  describes  certain 
protozoon-like  bodies  found  in  the  skin  of  scarlet  fever  cases  which  are  of 
interest,  but  their  pathological  and  etiological  importance  has  not  yet  been 
determined.  Vipond  isolated  a  bacillus  with  which  he  produced  in  monkeys 
a  scarlet  rash  and  fever. 

The  lesions  in  scarlet  fever  are  not  characteristic;  well-defined,  acute 
dermatitis,  ending  in  desquamation,  is  the  most  distinctive.  The  angina, 
which  produces  a  marked  congestion  and  inflammation  of  the  tonsils, 
pharynx  and  soft  palate,  with  a  grayish-white  exudation  due  to  the  action 
of  cocci,  is  also  commonly  present.  The  other  lesions  on  the  part  of  the 
lungs,  kidneys,  joints,  lymphatic  glands,  and  cellular  tissue   are  complica- 


318  SCAELET  FEVER 

tioDs  due  rather  to  the  action  of  cocci  than  to  the  specific  organism  which 
produces  scarlet  fever. 

Period  of  Incubation. — The  period  of  incubation  has  perhaps  a  wider 
range  than  in  any  of  the  other  acute  infections.  According  to  McCollom, 
it  varies  from  four  to  twenty  days,  the  average  period  being  ten  to  four- 
teen days.  Most  other  writers  name  a  shorter  period  of  incubation,  the 
average  being  six  or  seven  days.  A  number  of  well-authenticated  instances 
are  on  record  where  it  has  developed  within  twenty-four  hours  after  ex- 
posure, and  the  evidence  also  seems  to  be  conclusive  that  the  incubation 
stage  may  be  prolonged  for  fifteen  or  twenty  days. 

Symptomatology. — Scarlet  fever  is  a  disease  that  presents  the  widest 
variations  in  its  symptomatology,  from  a  mild  angina  which  may  not  be 
recognized  to  foudroyant  cases  where  the  toxemia  is  so  intense  that  the 
patient's  life  is  destroyed  within  twenty-four  hours.  The  following  de- 
scription represents  a  moderately  severe  case  of  typical  scarlet  fever; 
the  variations  from  this  type  will  be  considered  later. 

Onset. — A  feeling  of  malaise,  covering  a  period  of  one  or  two  days, 
may  precede  the  inore  characteristic  symptoms,  but  in  the  great  majority 
of  cases  the  onset  of  the  disease  is  marked  by  vomiting,  headache,  fever, 
and  sore  throat.  This  symptom  group,  which  is  more  or  less  suggestive  of 
scarlet  fever,  may  be  accompanied  by  a  chill  in  older  children  or  convul- 
sions in  young  children.  Within  the  first  twenty-four  hours  a  scarlet  rash 
commonly  appears  on  the  chest  and  neck,  and  gradually  extends  over  the 
body.  During  the  second  week  desquamation,  the  most  characteristic  of  all 
the  symptoms,  makes  its  appearance.  None  of  the  above  symptoms,  how- 
ever, are  absolutely  characteristic,  any  of  them  may  be  absent,  but  in  the 
great  majority  of  cases  the  syndrome  of  scarlet  fever  made  by  the  above 
symptoms  is  sufficiently  distinct  to  make  a  diagnosis.  The  severity  of  the 
disease  may  be  predicted  in  a  measure  by  the  suddenness  and  violence  of 
its  onset. 

Vomiting  occurs  in  about  70  to  80  per  cent,  of  the  cases  and  commonly 
marks  the  onset  of  the  disease.  It  may  be  repeated  a  number  of  times 
and  then  subside.  Prolonged  and  continuous  vomiting  is  not  character- 
istic. When  vomiting  occurs  late,  after  the  other  acute  symptoms  have 
subsided,  it  is  a  more  serious  symptom  and  may  mean  a  beginning  uremia. 
In  young  children  a  diarrhea  may  accompany  the  vomiting,  but  this  symp- 
tom rarely  persists  longer  than  two  days. 

Fever. — A  rise  in  temperature  immediately  follows  the  vomiting.  The 
fever  commonly  reaches -its  height  by  the  end  of  the  second  day,  but  the 
maximum  temperature  may,  in  some  cases,  be  found  at  the  end  of  the  first 
twenty-four  hours;  a  temperature  of  102°F.  indicates  a  mild  infection,  and 
105°  F.  or  over,  a  severe  one.  Following  the  rapid  rise  in  temperature  of 
the  first  two  days,  the  fever  usually  begins  to  subside,  getting  lower  day 
by  day  until  by  the  end  of  the  week  it  may  reach  normal.  It  may,  even 
in  uncomplicated  cases,  last  from  twelve  to  fourteen  days.  There  is  noth- 
ing characteristic  in  the  temperature  curve  of  scarlet  fever,  and  its  value 


SYMPTOMATOLOGY 


319 


as  a  diagnostic  sign  depends  largely  upon  its  association  with  the  other 
symptoms.  A  rise  in  the  temperature,  after  it  ha.s  been  slowly  falling  for  a 
number  of  days  or  after  it  has  become  normal,  indicates  some  complication, 
such  as  adenitis  or  otitis. 


o 

2 

1 

FAHRENHEIT    TEMPERATURE 

5„      s„      s„      i      §      s       i       2      §      i      S 

o 

■n 

oo 

»> 

o 

zo 

z 

2tl 

130 

c 

ILOMEL    J 

-" 

541.T! 

»^ 

ao««itte| 

). 

4  P.M. 

1 

8 

90 

HO 

KT1T0«1I 

V 

•-^ 

8  P.H 

li 

lis 

Br 

Hunt  Rl 

b. 

Tfp., 

Spunj. 

/ 

""' 

9  P.M. 

M 

M2 

THROAT 

AHD  EAR 

■  rJ 

GATI 

0  2   HOUl 

LT. 

y 

/^ 

,^'' 

H.4. 

M 

lU 

/. 

,^'' 

3  A.M. 

I 

9 

» 

ISO 

UR.«  ^ 

8 

/i-"' 

S 

OOL      0 

RA.ai. 

28 

HO 

•\. 

8  A.M. 

a 

l« 

>^T 

1 

RIGATE 

2  MOURl  r 

Moo. 

a 

IJS 

y 

I  P.H. 

n 

tM 

> 

8  P.M 

» 

IX 

t>^ 

«.  Ci 

OR.    X 

•  P.M. 

x 

l» 

Brilliant 

lUl 

1. 

X 

MkI. 

a 

128 

•''Z/' 

3«.H 

3 

10 

n 

12? 

URiKt    W 

^} 

Y^ 

S 

OOL     T\ 

8  A.M. 

a 

I/O 

\     J 

■i  KM. 

IS 

112 

Noo. 

» 

129 

\  ;3 

K    C 

T     <  >  0 

J  P.M 

th 

120 

i' 

;r.  »_ 

8  PM. 

w 

lie 

/   N 

TRCATM 

•IT  CONT 

XUEO 

8  P  N 

J6 

1^1 

; 

«    Cil 

OR.    X 

MkI. 

« 

1* 

"/ 

! 

X   NIOMT 

1  A.M. 

4 

II 

»8 

122 

JRINE  29 

\ 

Rjsb  lad 

ng 

SI 

301    77 

8A.M 

tt 

11? 

\     *■•. 

^ 

»  A.M 

ti 

IK 

.T-** 

Noo. 

a 

Itf 

•e^"^ 

4  P.M. 

f 

to*. 

> 

TR 

AIMEHT 

ANO  MED 

CINE  CO' 

TlNUEO 

•  P.M. 

a 

lue 

/ 

9PM 

« 

no 

/ 

"^ti 

Hid. 

« 

lit 

/'-r 

i  A.M. 

5 

12 

»» 

100 

/Bi'.E  47 

\ 

•< 

» 

Rasb 

BlinoM  go 

■e. 

"ii 

W    T 

8  AM 

It 

IXI 

N'--^ 

9  A.W. 

2< 

lul 

> 

hOM 

Zt 

IM 

2PM 

t* 

>oe 

S. 

«  P.M. 

u 

no 

i 

^    \ 

K     Cil 

iR.    7    » 

X    NIGHT 

9PM 

21 

112 

/ 

,> 

M.). 

»« 

110 

;«li.E  4S 

} 

V 

Ra 

b  guoc 

s 

001     7 

8  AM 

6 

13 

24 

88 

A 

9  A.M 

ti 

84 

/^ 

Noc 

H 

88 

4.^ 

\ 

TR 

ATMEP.T 

AND  MEO 

cine  CO 

TlNUEO 

1  P.M. 

U 

I0< 

■> 

8  P.M 

n 

IM 

/ 

9  P.M. 

M 

102 

,/ 

MkL 

7 

14 

24 

■  0< 

JRINE  SG 

^ 

/' 

D«q    at 

lin;rT>. 

ST 

>0I.      11 

6  A.M. 

12 

It 

>. 

9  A.M. 

n 

(1 

y 

Nooo 

a 

n 

• 

TREATl 

E«T  CON 

INUEO. 

2  P.M. 

2< 

TO 

' 

6  P.M 

a 

76 

/ 

9  P.M. 

8 

IS 

i« 

84 

JRIKE  «0 

} 

s- 

OOt.      1  1 

8  AM 

u 

« 

*X 

9  A.M. 

21 

ao 

> 

Fiogeri  : 

I*** 

Nooo 

21 

m 

/•' 

3  P.M. 

92 

T6 

8  P.M. 

- 

- 

4  P.M. 

9 

16 

- 

- 

JRINE  90 

} 

w 

s 

rOOl    T 

6  A.M 

22 

ao 

\» 

9  A.M. 

21 

•4 

NK.O 

22 


320 


SCARLET  FEVER 


The  pulse  rate  in  scarlet  fever  is  usually  high;  in  even  mild,  uncom- 
plicated cases  with  a  temperature  below  103  °F.    the  pulse  may  run  from 


■flM  « 





~~^ 

- 

" 

■K-d  i 

■M  r 

V,, 

oooj; 

•fiqoi 

Utt 

1  PO' 

*^ 

u 

II 

•WVB 

OMU 

>M' 

>«»<T 

ataf 

^ 

r-nr 
"nT" 

»  y  9 

' 

K-)\ 

n  V  c 

X 

•i»n 

^^--^ 

•w.»« 

n-d  9 

•KM  t 

s 

SZ 

"•»»! 

» 

-w-y  9 

r 

\l 

01 

•WV  II 

\ 

!XD 

B'V  r 

HV  9 

•PK 

' 

■i»n 

•HM« 

lafT 

FiSloS 

W^i 

Iql. 

* 

n  A 

KM« 

1 

'*?"; 

if 

»-d  9 

X 

KMf 

< 

\ 

'H-^r 

\  ^ 

""•S 

A 

°°»>l 



— 

^ 

•.^— 

— 

- 

> 

>2 

K-VS 











_i 

i 

tn 

w 

6" 

^.,  , 





-;^ 

>•— 

-| 

Mj 

CO' 
•n  A 

K  VC 













-i 

' 

-n't,- 

H  V  r 

f-' 

V 

P-K 

/ 

•p-n 

1 

K  a  • 

( 

•KM« 

I. 

/* 

H'd  9 

K'd  9 

Ka  c 

■KM  t 

^-^ 

■oe^ 

T 

°o»M 

l-^ 

e 

£2 

K'V  « 

not 

•KVH 

r' 

1 

K-y  9 

\ 

61 

8 

•K-y  9 

} 

OANI 

-Ka  C 

BV  t 

; 

/ 

H-d  9 

■P'lt 

/ 

/ 

-KMf 

-spa 

:qpa 

J 

^ 

•KM  « 

' 

/ 

•K-V  C 

*nai^ 

oW« 

*)»( 

H-d  9 

v_' — 

z 

22 

n-y  9 

^ 

nnr 

■If  J  t 

Kd  « 

^ 

""M 

V 

K'd  9 

< 

•K  V  6 

Ka  r 

81 

: 

H'V  • 

y 

n<»t{ 

S' 

•KV  t 

OANI 

•n-/f 

-K-V  6 

b 

l(T) 

l'A"X 

fn 

.  7 

^ 

1 

12 

•n'y  9 

I 

•K-a« 

>■/ 

•KM  8 

> 

m-d  » 

i 

n'd  9 

^^ 

■n-at 

Ka  r 

< 

■ooN 

\ 

>> 

« 

•»o«J 

V 

K  V  a 

\ 

KV  1! 

N 

l-\ 

9 

N'y  9 

IC 

02 

n  y  9 

->*> 

poy 

n  V  c 

\ 

p 

-K-a  « 

qm.| 

I>»0| 

■ipa- 

q  ao 

b«0 

i»i» 

\ 

^' 

Kd  9 

1 

•K-a  t 

if 

■Kar 

K 

Kd  > 

V 

■'fc^ 

•OOM 

•K-a  f 

KVIi 

!t 

fOOfl 

N.< 

0£ 

61 

■M-y  9 

^ 

02? 

K  V  6 

•w: 

ppj 

»  ftni' 

t  ao 

«<i 

V 

K  a  6 

<, 

91 

S 

H  V  9 

•KMt 

^ 

r-rx 

KV  ► 

*.v 

KV  « 

,— * 

K-V  I 

/'> 

62 

81 

■X  y  % 

'~ 

•K-a« 

y 

-Ka« 

V 

^ 

•■•d  • 

kS' 

'n'd  9 

< 

R  d  > 

auoa 

^»H 

■'' X 

•Kar 

\  5* 

K  d  I 

*^ 

s 

•~>M 

^^ 

•K  V  I 

"^ 

■<,\ 

•K  V  IS 

\ 

SI 

t 

N'y  9 

R?; 

l\ 

'n'y  9 

rpy 

(  X  X 

K  V  e 

Ka  e 

X 

■VH 

J 

/■' 

'Ifd  9 

^ 

•K'J« 

^ t 

Ka  r 

i 

M  d  9 

> 

•ooM 

^ 

- 

,- 

(JiJ 

nni 

•K-JC 

V 

, 

•KVd 

poq  i 

^11119 

:a.tn  ' 

«fl 

OBS 

•OOM 

9 

"IP"; 

??IH 

> 

\ 

11 

91 

n'y  9 

► 

■KV« 

\ 

•K-a  « 

^ 

- 

>l 

e 

K-y  9 

/ 

n^d  9 

^' 

H  V  C 

J 

•K-ar 

< 

\ 

P-K 

<* 

■"•M 

>• 

■KM« 

K  V  8 

L> 

(-r)i 

i-)rx 

n-a  » 

1 

9Z 

SI 

n'y  9 

' ' 

KM  t 

J 

f 

-KM  « 

"«>S 

•r^ 

/ 

n'd  9 

•K  V  « 

y 

•K-a  f 

01 

I 

wy  9 

X, 

OOOK 

^■^ 

M  V  c 

•i^ 

•K'Vt 

\ 

'; 

lC) 

orx 

CK 

> 

92 

tl 

n'y  » 

\ 

- 

•K-J« 

Wd  9 

^»aio| 

l.pi 

luMl 

3  an 

l)«(T 

1 J 

H'd  > 

\ 

•K'a  r 

\( 

•K-a  c 

•K'V  6 

\ 

> 

«»K 

1- 

W 

CI 

n'y  9 

^ 

1 

(' 

)Tn 

•nrx 

K  V  IS 

lA 

nd  9 

f 

V 

l\ 

1 

K-y  9 





_ 

_ 

31 

lun 

K'a  t 









\. 

t- 

_ 

m 

— 

■PK 



~7" 



mx^ 

— 

- 

W 

21 

•K  V  6 









"1 

; 

hh 

lorx 

„n(Uy 

•K-a  M 

— ^ 

n-y  9 

\ 

I 
z 
o 

S 

o 
> 

u 

5 

o 

>• 

u 

S 

3UnxVtl3dW3X   XI3HN3UHVd 

I 
1- 

2 

o 

z 

o 

J 

o 

< 
o 

o 

> 

u 

S 
P 

3UniVU3dW3X  XI3HN3UHVJ 

140  to  160;  in  the  more  severe  cases  it  may  reach  170  or  200  per  minute, 
but  this  high  pulse  rate,  out  of  proportion  to  the  temperature,  does  not 


SYMPTOMATOLOGY  321 

necessarily  mean  an  unfavorable  prognosis;  it  is,  however,  a  symptom  of 
diagnostic  value. 

Sore  Throat. — The  sore  throat  which  is  almost  always  present  is,  when 
taken  in  connection  with  the  other  symptoms,  of  great  value  in  diagnosis. 
It  manifests  itself  in  four  types:  (o-)  Simple  pharyngitis  with  swelling  of 
the  pillars  of  the  fauces  and  tonsils;  (&)  more  intense  swelling  and  infiltra- 
tion of  these  tissues  with  grayish  white  deposits  in  and  around  the  tonsillar 
crypts;  (c)  diphtheroid  angina  with  intense  infiltration  of  pharyngeal 
structures,  associated  with  adenitis  and  cellulitis  of  the  neck;  {d)  true 
diphtheria.  In  the  early  examination  of  the  mouth  in  suspected  scarlet 
fever  cases,  one  may  sometimes  make  out  that  the  roof  of  the  mouth  is  not 
only  red  and  congested,  but  that  it  has  also  fine  points  of  deeper  redness 
scattered  over  it,  which  give  it  a  punctate  appearance.  This  enanthem 
when  present  is  a  valuable  diagnostic  sign. 

Other  Gexeral  Symptoms. — Cervical  adenitis  of  the  glands  at  the 
angle  of  the  jaw  occurs  in  the  majority  of  cases.  WHien  the  throat  inflam- 
mation is  severe,  ulcerative  and  necrotic,  the  cervical  lymph  nodes  are  more 
seriously  involved.  These  glands  may  enlarge,  forming  tumor  masses  bound 
together  by  an  inflammation  of  the  cellular  tissue  which  may  result  in  a 
more  or  less  board-like  tumefaction.  This  condition  is  an  ominous  one; 
it  may  result  in  a  dry  necrosis,  causing  great  destruction  to  the  tissues  of 
the  neck  and  a  subsequent  general  septicopyemia.  This  severe  form  of 
adenitis  is  to  be  considered  rather  as  a  complication  than  as  a  symptom 
of  the  disease,  but  even  the  milder  cases  may  result,  in  a  suppurating 
adenitis,  especially  in  tuberculous  children.  This  process  occurs  more  com- 
monly in  children  suffering  from  latent  tuberculosis. 

Tlie  Tongue. — The  appearance  of  the  tongue  is  of  more  diagnostic 
value  in  scarlet  fever  than  in  any  other  general  disease.  In  the  beginning 
it  is  covered  with  a  white  coat  through  which  small  red  papillae  are  seen  to 
protrude;  after  two  or  three  days  the  white  coating  disappears,  leaving  it 
red,  but  the  papillgs  still  stand  out  prominently  as  little  dots  of  redder 
hue;  these  are  to  be  seen  along  the  edges  and  especially  on  the  tip  of  the 
tongue,  and  give  to  it  a  strawberry  appearance,  hence  the  term  "straw- 
berry tongue,"  first  described  by  Flint. 

Eruption. — The  rash  of  scarlet  fever  generally  makes  its  appearance 
on  the  neck  or  chest  within  the  first  twenty-four  or  thirty-six  hours;  it 
may,  however,  be  delayed  until  the  third  or  fourth  day,  and  in  rare  in- 
stances even  as  late  as  the  sixth  day,  and  is  usually  accompanied  by  more 
or  less  itching.  The  eruption,  within  two  days  after  its  appearance,  spreads 
to  all  parts  of  the  body.  In  the  beginning  it  has  a  punctate  appearance 
produced  by  small  red  points  closely  approximated  and  scattered  in  patches 
over  the  skin,  which  coalesce,  and  in  the  course  of  twenty-four  hours  the 
punctate  appearance  may  be  lost  in  a  uniform  scarlet  eruption  which  dis- 
appears on  pressure.  The  rash  takes  on  a  deeper  scarlet  hue  and  reaches 
its  maximum  of  redness  in  two  days;  it  then  gradually  fades,  entirely  dis- 
appearing in  from  four  to  seven  days.    The  face  may  remain  free  or  show 


323  SCARLET  FEVER 

only  slight  signs  of  the  eruption,  but  even  when  the  skin  of  the  face  is 
covered  with  the  scarlet  rash  there  is  a  peculiar  pallor  about  the  mouth, 
and  herpes  may  also  be  present.  The  rash  is  more  intense  in  those  regions 
of  the  body  where  the  folds  of  the  skin  are  brought  into  juxtaposition, 
such  as  the  axilla,  the  inguinal  region,  the  under-surface  of  the  elbow  and 
knee  joints,  the  folds  of  the  buttocks,  and  approximated  surfaces  of  the 
thighs.  The  rash  of  scarlet  fever  varies  greatly  in  different  cases;  it  may 
not  be  present  at  all,  it  may  last  but  a  few  hours,  it  may  appear  in  but 
a  few  punctate  patches  on  the  parts  of  the  body  where  the  skin  is  in 
juxtaposition,  or  it  may  present  the  typical  appearance  just  described  and 
be  followed  by  miliaria  or  urticaria.  In  malignant  cases  it  may  be  hemor- 
rhagic. 

Desquamation,  which  is  perhaps  the  most  characteristic  symptom  of 
scarlet  fever,  commences  about  the  seventh  day;  in  severe  cases  it  may 
begin  earlier,  in  mild  cases  later.  It  continues  from  three  to  six  weeks,  or 
in  severe  cases  longer.  The  character  and  extent  of  the  desquamation 
depend  largely  upon  the  severity  of  the  dermatitis;  if  this  be  severe  and 
marked  by  a  uniformly  brilliant  scarlet  eruption,  the  desquamation  that 
follows  is  more  extensive  and  the  epithelium  is  peeled  off  in  larger  flakes. 
In  the  milder  cases  it  may  be  almost  or  quite  absent ;  in  such  instances  it 
should  be  sought  for  especially  in  the  axillary  and  inguinal  regions,  and 
under  the  finger  nails.  Desquamation  begins,  as  a  rule,  on  the  neck,  chest, 
and  fingers  and  spreads  to  other  portions  of  the  body,  the  skin  of  the  feet 
being  the  last  to  peel.  It  may  be  fine  and  scaly,  like  the  furfuraceous 
desquamation  of  measles;  it  is,  however,  more  commonly  flaky  or  lamellar 
in  character.  The  older  the  child,  and  the  more  hardened  and  tougher 
the  skin,  the  more  marked  the  desquamation.  On  the  hands  and  feet  the 
epidermis  may  be  peeled  off  in  large  pieces;  entire  casts  of  the  fingers  and 
hands  have  been  removed  in  some  instances.  Secondary  desquamation 
may  occur,  especially  in  the  more  severe  cases. 

Urine. — The  urine  should  be  examined  frequently  from  the  onset  of 
the  disease  until  desquamation  has  ceased.  A  trace  of  albumin  is  present 
in  from  10  to  15  per  cent,  of  the  cases;  this  slight  albuminuria,  even 
when  accompanied  by  a  few  hyalin  casts,  is  not  an  ominous  symptom.  It 
may  be  a  simple  febrile  or  toxic  albuminuria,  more  commonly  present  in 
this  disease  than  in  other  fevers,  because  the  skin  is  largely  put  out  of 
action  and  the  kidneys  are  therefore  called  upon  to  do  extra  work.  The 
presence  of  albumin,  however,  associated  with  granular  and  epithelial  casts, 
is  a  much  more  serious  matter,  and  indicates  the  onset  of  acute  nephritis. 
The  kidney  complications  of  scarlet  fever  are  commonly  post-scarlatinal, 
occurring  after  the  acute  symptoms  have  subsided.  This  subject  is  con- 
sidered in  the  chapter  on  Acute  Nephritis. 

Blood. — There  is  a  slight  secondary  anemia  with  a  moderate  reduc- 
tion of  both  hemoglobin  and  red  blood  corpuscles.  Between  the  second  and 
eighth  day  there  is  a  leukocytosis  of  eighteen  to  forty  thousand;  the  poly- 
morphonuclear leukocytes  are  relatively  and  absolutely  increased  early  in 


IRREGULAR  CLINICAL  TYPES  323 

the  disease,  and  rapidly  diminish  as  the  fever  and  toxemia  subside.  The 
mononuclears  are  relatively  and  absolutely  increased  in  the  later  stages. 
The  eosinophiles  are  increased  as  the  toxemia  subsides. 

Recurrence  and  Relapse. — One  attack  of  scarlet  fever  confers  perma- 
nent immunity.  This  is  a  rule  which  has  but  few  exceptions,  although 
very  rarely  second  attacks  may  occur.  A  relapse,  while  also  rare,  is  more 
common  than  a  recurrence  from  reinfection ;  it  may  occur  during  the  third 
or  fourth  week  and  produce  the  symptom  group  in  a  milder  form.  A 
return  of  the  eruption  within  two  or  three  days  after  its  disappearance  is 
not  to  be  confounded  with  a  true  relapse,  since  its  return  at  this  time  is 
usually  of  little  moment,  and  it  disappears  shortly  without  being  accom- 
panied by  other  untoward  symptoms. 

Irregular  Clinical  Types. — From  the  ordinary  type  above  described 
there  are  a  number  of  important  clinical  variations. 

Mild  Type. — Scarlet  fever  may  manifest  itself  in  a  form  so  mild  that 
the  character  of  the  disease  may  not  be  suspected  and  the  infected  child 
may  unintentionally  spread  the  disease  broadcast.  A^omiting  may  or  may 
not  be  present,  there  is  a  slight  elevation  of  temperature,  which  soon  falls 
to  normal,  and  the  patient  is  thought  to  have  an  ordinary  tonsillitis  or 
pharyngitis.  The  true  nature  of  the  infection  may  be  determined  by  pre- 
vious or  subsequent  cases  of  scarlet  fever  in  the  same  family  or  by  the  ap- 
pearance of  a  slight  eruption,  followed  by  furfuraceous  desquamation  in 
the  axilla  or  groins.  The  enanthem  or  fine  punctate  eruption  on  the  roof 
of  the  mouth  may  be  present,  and  should  always  be  looked  for  in  every 
case  of  sore  throat  or  scarlatinaform  eruption. 

Malignant  or  Fulminating  Type. — Cases  of  this  character  are  very 
uncommon.  Within  the  course  of  a  few  hours  the  child  may  be  so  over- 
whelmed with  the  poison  that  the  hopelessness  of  the  case  is  apparent. 
In  the  most  severe  cases  death  may  occur  within  two  days;  as  a  rule, 
however,  the  disease  lasts  from  three  to  six  days.  The  onset  is  marked  by 
severe  nervous  symptoms  which  may  suggest  meningeal  involvement;  con- 
vulsions, delirium  and  coma  may  follow  each  other  in  quick  succession. 
The  child  tosses  about  in  bed  and  cannot  be  quieted;  the  fever  from  the 
onset  is  high,  the  pulse  rapid,  and  death  commonly  results  either  from 
acute  cardiac  dilatation  or  from  slow  cardiac  failure.  If  the  patient  lives 
long  enough  a  severe  sore  throat  and  scarlet  eruption  appear;  in  some  in- 
stances the  rash  is  hemorrhagic.  In  the  most  violent  of  these  cases  the 
diagnosis  is  difficult  and  at  times  impossible,  as  the  patient  does  not  live 
long  enough  to  develop  typical  symptoms.  Between  the  mild  and  malignant 
types  we  may  have  every  grade  of  severity.  In  the  same  epidemic  we  may 
see  both  mild  and  malignant  cases. 

Septic  Type. — Accurately  speaking,  this  is  a  complication  rather  than 
a  type  of  scarlet  fever,  but  as  previously  noted,  the  role  played  by  septic 
organisms  in  producing  the  symptom-complex  of  scarlet  fever  is  very  great, 
and  in  a  large  percentage  of  the  cases  the  septicemia  or  septicopyemia 
presents  such  a  distinct  symptom-complex  that  it  has  come  to  be  considered 


324  SCARLET  FEVER 

as  a  type  of  this  disease.  The  onset  is  that  of  severe  scarlet  fever,  but  as 
the  fever  begins  to  subside  a  slight  or  sudden  rise  in  the  temperature 
occurs.  This  secondary  rise  is  a  most  significant  symptom,  and  is  usually 
accompanied  by  an  enlargement  of  the  cervical  lymphatics.  Upon  these 
two  symptoms  alone  one  is  justified  in  assuming  that  the  time  has  come 
to  use  our  most  energetic  therapeutic  measures  for  controlling  septicemia. 
If  the  condition  is  not  controlled,  the  temperature  continues  high  with 
marked  variations  and  may  run  for  many  weeks.  At  times  it  is  not  unlike 
the  temperature  of  typhoid  fever  or  of  general  miliary  tuberculosis.  The 
throat  symptoms  and  all  other  symptoms  of  scarlet  fever  may  gradually 
disappear,  leaving  the  symptom-complex  of  a  septicopyemia.  Suppuration 
of  the  lymphatic  glands  of  the  neck  may  occur  and  a  septic  pericarditis, 
arthritis,  pleuritis  or  bronchopneumonia  may  develop. 

Complications. — Otitis  media  is  a  very  common  complication.  It  oc- 
curs in  from  15  to  20  per  cent,  of  hospital  cases,  but  is  less  in  private 
practice ;  it  is  a  sequel  of  the  pharyngitis  of  this  disease  and  is  more  com- 
mon in  tuberculous  children.  In  the  treatment  of  every  case  of  scarlet 
fever,  and  especially  in  those  with  tuberculous  family  histories,  the  pos- 
sibility of  the  development  of  otitis  media  should  constantly  be  kept  in 
mind  and  a  secondary  rise  in  temperature  should  always  lead  to  a  careful 
examination  of  the  ear.  In  infants,  apparently  convalescent  from  scarlet 
fever,  this  complication  may  be  suspected  if  the  child  suddenly  becomes 
restless,  sleepless  and  cries  with  pain. 

Ulcerative  and  gangrenous  angina,  which  may  result  in  the  destruction 
of  the  tissues  of  the  throat,  is  much  to  be  dreaded  but  is  fortunately  rare. 

The  septic  arthritis,  which  may  occur  as  a  part  of  the  symptom-complex 
of  the  septicopyemia  of  scarlet  fever,  is  multiple,  commonly  involves  the 
large  joints  and  is  sometimes  associated  with  purpura.  There  is,  however, 
another  form  of  scarlatinal  arthritis,  producing  an  acute  inflamma- 
tion of  the  synovial  membranes,  not  associated  with  pus  formation.  This 
condition  is  spoken  of  as  scarlatinal  rheumatism.  It  is  a  rare  but 
very  well  defined  symptom  group;  the  wrist  and  finger  joints  are  most 
commonly  involved,  but  some  of  the  large  joints  of  the  extremities 
may  also  be  affected.  It  produces  fever,  with  redness,  tenderness  and 
SM'elling  of  the  joints,  and  it  may  produce  pericarditis  and  true  endo- 
carditis, leaving  the  valves  of  the  heart  permanently  injured.  Both 
the  arthritic  and  cardiac  symptoms,  however,  are  on  the  whole  much  less 
severe  than  they  are  in  true  articular  rheumatism.  Salicylic  acid  appar- 
ently relieves  the  pain  and  reduces  the  fever  which  occurs  in  this  condi- 
tion; whether  or  not  it  is  true  rheumatic  fever,  complicating  scarlet  fever, 
or  a  manifestation  of  the  scarlatinal  toxemia  is  not  altogether  clear.  The 
latter  hypothesis  is  more  rational. 

Nephritis  is  one  of  the  most  common  and  serious  complications  of 
scarlet  fever.  In  the  majority  of  instances  it  is  a  post-scarlatinal  lesion 
and  is,  therefore,  to  be  carefully  looked  for  during  and  after  the  third  week. 
It  may  be  made  manifest  by  a  slight  puffing  of  the  eyelids,  severe  head- 


PROGNOSIS  325 

ache,  sudden  rise  of  temperature,  nausea  or  vomiting,  but  the  diagnosis  is 
made  by  the  finding  of  albumin  and  casts  in  the  urine,  or  possibly  by  the 
sudden  development  of  convulsions  and  other  uremic  symptoms. 

Cardiac  murmurs  are  common  during  the  height  of  the  disease,  but  true 
endocarditis  is  rare.  Myocardial  degeneration  of  greater  or  less  degree  is 
very  common. 

Nervous  lesions  may  occur.  In  severe  cases  meningitis,  hemiplegia, 
chorea,  and  symmetrical  gangrene  are  occasionally  seen. 

Diagnosis. — There  is  perhaps  no  disease  in  which  it  is  more  important 
to  make  an  accurate  diagnosis  than  in  scarlet  fever.  The  responsibility 
of  the  physician  is  here  very  great.  On  the  one  hand  if  he  comes  in  con- 
tact with  a  mild  case  and  fails  to  make  the  diagnosis  great  damage  may  be 
done  by  spreading  the  disease  broadcast.  On  the  other  hand,  if  he  comes  in 
contact  with  one  of  the  numerous  rashes  that  so  closely  resemble  scarlet  fe- 
ver, and  condemns  the  patient  as  well  as  the  entire  household  to  six  long 
weeks  of  rigid  quarantine,  he  has  thereby  done  great  injustice  and  caused 
great  inconvenience.  Since  in  many  instances  it  is  absolutely  impossible  for 
the  physician  to  make  the  diagnosis  it  is  his  duty  to  quarantine  all  sus- 
picious cases  until  the  question  has  been  fully  settled.  In  the  ordinary 
case  the  diagnosis  is  easily  made  by  the  sudden  onset  of  vomiting,  sore 
throat  and  fever  followed  hj  the  rash,  the  "strawberry  tongue"  and  later 
the  desquamation.  Upon  one  point  in  the  differential  diagnosis  I  wish 
especially  to  insist,  and  that  is  upon  the  early  appearance  of  the  more  or 
less  typical  enanthem.  The  roof  of  the  mouth  is  red  and  congested,  and 
over  this  red  surface  fine  points  of  more  scarlet  hue  are  scattered  in  close 
juxtaposition.  When  this  condition  can  be  made  out  it  is  of  great  value  as 
an  early  diagnostic  symptom  in  distinguishing  scarlet  fever  from  measles 
and  rubella. 

The  erythematous  rash  of  influenza  associated  with  fever,  sore  throat 
and  gastric  disturbance  produces  a  clinical  picture  which  can  only  be 
differentiated  from  scarlet  fever  by  the  development  of  further  symptoms. 
Rashes  resembling  scarlet  fever  may  also  result  from  digestive  disturbances, 
sepsis  and  from  drugs  such  as  antipyrin,  quinin  and  atropin.  Acute  exfo- 
liating dermatitis  and  the  serum  rashes  following  the  use  of  diphtheria 
antitoxin  are  often  difficult  of  differentiation  from  scarlet  fever. 

Prognosis. — Age  is  one  of  the  most  important  determining  factors  in 
the  prognosis  of  scarlet  fever.  The  younger  the  patient  the  more  fatal 
the  disease.  From  a  study  of  5,000  cases  of  scarlet  fever,  treated  at  the 
South  Department  of  the  Boston  City  Hospital,  McCollom  found  the 
death  rate  to  be  over  33  per  cent,  in  children  under  one  year  of  age.  This 
mortality  rapidly  decreased  so  that  between  the  sixth  and  seventh  year  it 
was  about  7  per  cent.  From  this  time  on  there  was  a  very  gradual  de- 
crease in  the  death  rate.  The  accompanying  chart  graphically  illustrates 
the  increasing  powers  of  resistance  which  age  gives  to  this  disease. 

The  character  of  the  epidemic  is  also  important  in  determining  the 
death  rate.     Some  epidemics  are  characterized  by  unusually  severe  cases 


326 


SCARLET  FEVER 


with  great  mortality.  Others  are  mild  and  the  mortality  is  correspondingly 
low.  The  mortality,  especially  during  the  first  two  or  three  years  of  life, 
is  much  lower  in  private  than  it  is  in  hospital  practice.  This  is  not  only 
due  to  the  early  medical  attention  which  private  cases  receive,  but  also 
to  the  fact  that  these  children  are  much  better  nourished  and  have,  on 
the  whole,  greater  powers  of  resistance  than  the  malnourished  weaklings 
that  find  their  way  to  public  hospitals.  The  general  mortality  of  scarlet 
fever  at  all  ages  is  variously  estimated  by  different  writers;  it  is  on  the 


z 
111 
o 

K 
UJ 

a 

55 

ou, 

3  .> 

< 
> 

o 

1- 

< 

2 

< 
> 

> 

o 

1 

> 
« 
o 

s 

< 

cc 

< 

> 
O 

1 

> 
o 

1 

o 

O 

1- 

< 

O 
o 

< 
> 

o 

t- 

CO 
CE 

< 

o 

t- 

< 
> 

O 

s 

< 

> 

o 

< 

1 

> 

33.00 

31.00 

29.00 

27.00 

25.00 

23.00 

21.00 

19.00 

17.00 

15.00 

13.00 

11.00 

9.00 

7.00 

5.00 

8.00 
1.00 

\ 

\ 

\ 

\ 

V 

A 

\ 

\ 

\ 

\ 

\ 

\ 

A 

V 

N 

V 

/ 

V 

-*• 

./K 

"A, 

-/ 

r 

V 

X 

Fig.  54. — Mortality  by  Age  in  5,000  Cases  of  Scarlet  Fever.    (McCoUom.) 


average  about  12  per  cent.  In  the  individual  child,  apart  from  its  age 
and  the  severity  of  the  prevailing  epidemic,  the  severity  of  the  onset  is 
the  most  important  prognostic  factor.  High  temperature,  convulsions, 
profound  nervous  symptoms,  and  a  bad  sore  throat  with  extensive  involve- 
ment of  the  cervical  lymph  nodes  indicate  that  the  child's  life  is  in  peril. 
Dangers  may  beset  the  child  from  the  onset  of  the  disease  until  the  com- 
pletion of  its  convalescence.  In  the  beginning  the  danger  is  that  it  may 
be  overwhelmed  by  the  violence  of  the  toxemia.     Toward  the  end  of  the 


PROPHYLAXIS  327 

first  week,  violent  throat  symptoms  with  a  beginning  septicemia  may 
foretell  an  unfavorable  termination,  and  throughout  its  convalescence, 
nephritis,  bronchopneumonia  and  a  general  septicopyemia  may  place 
the  child's  life  in  peril.  With  all  of  these  unforeseen  dangers  the  prog- 
nosis in  any  individual  case  is  uncertain,  even  though  the  present  condi- 
tions are  favorable. 

Prophylaxis. — The  prophylactic  treatment  of  scarlet  fever  is  perhaps 
more  important  than  that  of  any  other  disease.  The  most  important  ob- 
ject to  be  obtained  is  the  absolute  isolation  of  the  sick  child  from  everyone 
except  the  necessary  attendants.  This  is  a  matter  not  only  of  the  greatest 
difficulty,  but,  in  the  majority  of  instances,  it  is  absolutely  impossible. 
Among  the  children  of  the  poor,  the  patient  should  be  removed  to  a  con- 
tagious-disease hospital.  Among  the  rich,  the  problem  of  isolation  is 
not  so  difficult.  Among  the  middle  class,  the  question  of  expense,  which 
absolute  isolation  entails,  is  a  very  serious  hindrance  to  the  proper  prophy- 
lactic treatment  of  scarlet  fever.  There  are,  however,  certain  recognized 
principles  in  the  home  treatment  which  the  physician  should  endeavor  to 
follow,  conforming  as  closly  to  the  ideal  conditions  as  circumstances  will 
allow.  The  following  details  apply  not  only  to  scarlet  fever  but  to  diph- 
theria and  smallpox  as  well. 

As  soon  as  scarlet  fever  is  suspected  the  two  most  available  rooms  in 
the  house,  for  isolation  purposes,  should  be  selected;  one  for  the  patient 
and  one  for  the  nurse  off  duty.  All  rugs,  carpets,  hangings,  and  un- 
necessary articles  of  furniture  and  clothing  should  be  removed,  and  the 
rooms  furnished  with  iron  beds  and  with  such  chairs  and  tables  as  can 
be  easily  cleaned.  A  day  and  night  nurse  should  be  installed,  and  they 
should  have  entire  charge  of  the  rooms  and  the  patient.  The  fetching  and 
carrying  of  food,  clothing  and  other  things  to  and  from  the  room  should 
be  done  with  such  care  that  other  members  of  the  household  will  not  be 
infected.  The  physician  on  entering  the  room  should  put  on  a  fresh 
white  gown  and  cap,  and  should  remain  in  contact  with  the  patient  as 
short  a  time  as  possible,  and  on  his  exit  should  carefully  cleanse  and  dis- 
infect his  hands,  his  stethoscope,  or  any  other  instrument  he  may  have 
used.  The  nurse  should  be  directed  to  destroy  the  excretions  from  the 
throat  and  nose,  either  by  burning  or  by  placing  them  in  a  solution 
of  bichlorid  of  mercury.  There  is  no  danger  that  the  poison  of  scarlet 
fever  will  permeate  the  air  and  contaminate  halls  and  neighboring  rooms; 
for  this  reason  isolation,  when  intelligently  carried  out,  will  protect  the 
other  members  of  the  household  from  the  disease.  When  desquamation 
commences,  inunctions  with  oil  or  ointments  will  not  only  be  a  comfort 
to  the  patient,  but  will  prevent  the  scattering  of  the  scales  of  skin  through- 
out the  room ;  the  frequent  use  of  inunctions  is  therefore  a  most  important 
prophylactic  measure.  The  isolation  of  the  child  should  be  rigidly  kept  up 
until  desquamation  and  all  discharges  from  the  nose  and  throat  cease;  in 
the  average  ca^e  this  covers  a  period  of  six  weeks.  When  the  quarantine  is 
raised  the  patient's  body  should  be  thoroughly  washed  with  soap  and  hot 


3:^8  SCARLET  FEVER 

water,  and  his  hair  and  nails  carefully  cleansed  before  he  is  permitted 
to  leave  the  room  and  mingle  with  the  household. 

The  sick  rooms  should  be  fumigated  with  formaldehyde.  McCollom 
says :  "The  simplest  and  also  an  effectual  method  of  generating  formalde- 
hyde is  tliat  adopted  by  tlie  Maine  Board  of  Health,  which  consists  of  mix- 
ing potassium  permanganate  with  a  40-per-cent.  solution  of  formalin.  The 
potassium  permanganate  should  be  the  commercial  and  not  the  chemically 
pure.  No  special  apparatus  is  required.  An  ordinary  tin  dish  with  flaring 
sides  can  be  used.  The  quantity  of  permanganate  for  each  pint  of  formalin 
is  61/2  ounces.  It  is  very  important  that  the  permanganate  be  put  in  the 
dish  first,  and  then  the  formalin  solution  poured  over  it.  It  is  taken  for 
granted  that  the  room  has  been  tightly  sealed.  As  soon  as  the  formalin 
is  placed  in  the  receptacle  a  rapid  exit  must  be  made,  because  the  gas  is 
generated  very  quickly.  The  room  should  remain  closed  for  twenty-four 
hours  and  then  be  thoroughly  aired.  The  quantity  of  the  40-per-cent.  solu- 
tion of  formalin  and  of  the  potassium  permanganate  to  disinfect  500  cubic 
feet  of  space  is  1  pint  of  the  former  and  6i/4  ounces  of  the  latter."  Follow- 
ing disinfection,  the  woodwork  should  be  washed  with  soap  and  water  and 
then  rubbed  down  with  a  1 : 1,000  solution  of  bichlorid  of  mercury.  The 
wall  paper  should  be  cleaned  or  removed.  All  books  and  toys  should  be 
destroyed  and  the  bed  linen  should  be  treated,  as  throughout  the  course 
of  the  disease,  by  placing  it  first  in  a  bichlorid  solution  and  then  subjecting 
it  to  boiling.  The  mattress  should  be  burned.  Where  this  is  not  expe- 
dient, as  in  hospitals,  it  should  be  disinfected  by  steam.  Following  the 
cleansing  of  the  room,  it  should  a  second  time  be  fumigated  with  formal- 
dehyde. 

School  inspection  by  health  boards  is  one  of  the  most  valuable  prophy- 
lactic measures.  Where  this  is  systematically  carried  out  at  least  once  a 
week,  a  large  number  of  children  will  be  found  with  throat  and  nose  dis- 
ease, or  with  other  evidences  of  illness  which  justify  their  being  sent  home 
and  kept  under  proper  medical  supervision  until  they  have  recovered.  In 
our  large  cities,  where  school  inspection  is  now  being  successfully  carried 
out,  there  is  little  doubt  but  that  many  children  with  scarlatinal  angina  are 
prevented  from  mingling  and  spreading  the  disease  among  other  children. 
Clinical  reports  now  indicate  that  the  use  of  streptococcus  vaccines  may  be 
a  valuable  prophylactic  measure. 

Treatment. — There  is  no  specific  treatment  for  this  disease,  and  the 
physician  should  ever  keep  in  mind  that  it  is  self-limited  and  in  the  great 
majority  of  instances  runs  its  course  to  a  successful  termination.  These 
facts  being  understood,  it  is  most  important  that  medication  should  be 
given  only  when  medicines  are  indicated,  and  that  the  symptomatic  treat- 
ment should  not  be  overdone. 

The  patient  should  be  put  to  bed  and  kept  there  for  a  week  or  ten  days 
after  all  acute  symptoms  have  subsided;  this  materially  diminishes  the 
danger  of  renal  and  other  complications.  The  sick  room  should  be  well 
ventilated,  at  a  temperature  between  65°  and  70°  F.    The  bed  and  body 


TREATMENT  329 

linen  should  be  frequently  changed,  and  the  bed  covering  should  be  com- 
paratively light.  It  is  most  important  that  scarlet-fever  cases  should  not 
be  kept  overwarm  with  bed  clothing  and  by  living  in  superheated  rooms. 
During  the  first  forty-eight  hours  the  bowels  should  be  moved  with  calomel, 
followed  by  some  saline  laxative,  and  thereafter  kept  open,  if  necessary,  by 
the  use  of  some  mild  cathartic,  such  as  cascara. 

Dietetic  Treatment. — During  the  first  days  barley  water  and  mutton 
broth  may  be  given.  With  the  subsidence  of  the  vomiting  and  the  quieting 
of  the  stomach  the  milk  diet  is  begun.  Milk  in  some  form  should  be  al- 
most the  exclusive  diet  for  the  next  three  weeks;  one  or  two  quarts,  de- 
pending upon  the  age  of  the  child,  may  be  taken  within  twenty-four  hours. 
Milk  is  of  special  value  in  that  it  serves  nutritional  purposes,  is  easy  of 
digestion,  acts  as  a  diuretic  and  throws  very  little  work  upon  the  already 
overtaxed  kidneys.  It  will  sometimes  tax  the  ingenuity  of  the  physician 
to  maintain  the  milk  diet  throughout  this  period.  The  term  milk  diet,  as 
here  used,  includes  all  of  the  artificial  milk  foods,  ice  cream  and  butter- 
milk. The  milk  may  be  flavored  with  cocoa  or  vanilla,  mixed  with  cereal 
decoctions  or  made  into  milk-soups.  Certain  drinks,  such  as  lemonade 
and  orangeade,  never  mixed  with  albumin  water,  may  be  given.  During 
convalescence,  after  the  third  week,  other  foods  may  be  used,  such  as  bread, 
stewed  "fruits,  baked  apples,  rice  pudding,  cereals,  thick  soups,  and,  later, 
potatoes,  vegetables,  fish  and  chicken  may  be  added. 

Hydrotherapy  is  a  most  important  part  of  the  treatment.  In  all 
cases,  especially  where  the  temperature  runs  high,  baths  are  not  only  a 
valuable  therapeutic  measure  but  they  add  greatly  to  the  comfort  of  the 
patient.  In  the  milder  cases  sponge  baths,  with  water  at  a  temperature 
between  70°  and' 80°  F.,  should  be  given  twice  a  day.  In  severe  cases  tub 
baths  at  a  temperature  of  70°  F.  or  moderately  cold  packs  given  every  four 
or  six  hours  are  more  effective.  In  connection  with  these  baths,  an  ice-cap 
should  be  applied  to  the  head,  but  this  application  should  not  be  continuous, 
except  in  the  malignant  type  of  the  disease  where  the  fever  is  high  and  the 
nervous  symptoms  are  profound.  It  should  be  remembered,  in  applying 
the  various  measures  here  recommended,  that  all  children  do  not  respond 
kindly  to  cold  baths;  this  is  especially  true  of  infants.  On  the  whole,  it 
may  be  said  that  the  older  the  child  the  more  effective  and  the  more  sat- 
isfactory will  be  the  cold-bath  treatment.  But  in  any  given  instance,  if 
the  bath  produces  unfavorable  symptoms,  such  as  great  prostration,  weak 
heart,  cyanosis,  and  cold  extremities,  it  is  to  be  either  discontinued  or  so 
modified  as  to  get  the  good  without  producing  the  bad  results.  The  or- 
dinary coal-tar  antipyretics  should  not  be  used  for  the  control  of  the  tem- 
perature or  the  nervous  symptoms. 

Stimulants. — In  malignant  cases  stimulants  are  necessary  to  counter- 
act the  severe  onslaught  of  the  toxins  on  the  nervous  system  and  the  heart. 
For  this  purpose  whiskey,  brandy,  or  champagne  may  be  freely  given  during 
the  early  days  of  the  treatment.  Aft^r  the  poison  has  spent  its  force  and 
the  nervous  system  has  commenced  to  recover  from  its  effects  alcohol  is 


330  SCARLET  FEVER 

no  longer  indicated  and  finds  no  place  in  the  treatment  of  scarlet  fever ;  its 
use  after  this  period  may  be  injurious  to  tlie  kidney.  Other  stimulants, 
however,  may  be  used  in  connection  with  the  alcohol  and  may  be  continued 
throughout  the  course  of  the  disease;  the  most  valuable  of  these  are  stro- 
phanthus  and  digitalis.  They  are  especially  indicated  in  severe  and  pro- 
longed cases  of  scarlet  fever,  with  rapid  and  weak  heart.  Strophanthus  is 
especially  valuable  in  very  young  children  and  digitalis  in  older  children, 
and  both  of  these  drugs  should  be  combined  with  essence  of  pepsin  or  some 
other  palatable  vehicle  which  will  protect  the  digestive  organs  of  the  child. 
Strychnin  in  1/150  to  1/200-grain  doses  is  another  valuable  stimulant, 
acting  especially  on  the  respiratory  centers,  and  may  be  continued  through- 
out the  course  of  the  disease.  In  extreme  cases,  where  collapse  threatens, 
salt  solution  and  caffein  sodium  benzoate  may  be  given  in  the  same  dose 
and  manner  as  directed  under  Diphtheria. 

Inunctions  are  a  part  of  the  routine  treatment  of  scarlet  fever.  The 
child  should  be  anointed  twice  a  day  with  oil,  cocoa-butter,  lanolin,  cold 
cream,  or  lard.  They  prevent  the  scales  of  skin  from  being  scattered  about 
and  make  the  patient  more  comfortable  by  allaying  the  itching  and  irri- 
tation of  the  skin.  Seibert  recommends  the  use  of  a  10-per-cent.  icthyol 
lanolin  ointment.  Other  writers  advise  that  boric  acid  and  carbolic  acid  be 
combined  with  the  ointments  above  named.  The  general  consensus  of 
opinion  is  that  the  value  of  this  treatment  depends  upon  the  soothing  rather 
than  the  antiseptic  action  of  the  ointment. 

The  systematic  treatment  of  the  nose  and  throat  is  important;  for 
this  purpose  an  atomizer  may  be  used  containing  1  ounce  of  liquid  albolin, 
combined  with  10  minims  of  oil  of  eucalyptus  and  3  grains  of  menthol,  or 
some  alkaline  antiseptic  solution.  When  the  angina  is  severe,  mild  sa- 
line antiseptic  solutions  may  be  injected  through  the  nose,  coming  out 
through  the  pharynx,  in  the  manner  described  in  the  chapter  on  Therapeu- 
tics of  Infancy  and  Childhood,  and  the  throat  should  be  swabbed  alternately 
every  two  or  three  hours  with  a  1/1,000  bichlorid  of  mercury  solution  and 
a  30  per  cent,  argyrol  solution.  The  object  of  this  treatment  is  to  minimize 
the  systemic  intoxication,  to  modify  the  local  inflammatory  conditions,  and 
to  prevent  internal  ear  complications.  In  severe  gangrenous  inflammations 
of  the  throat  strong  nitrate  of  silver  solutions  and  even  the  thermocautery 
have  been  recommended.  Where  diphtheria  complicates  scarlet  fever  diph- 
theria antitoxin  should  be  given. 

With  the  onset  of  septicemic  symptoms  one  should  begin  the  use  of 
antistreptococcic  serum  made  from  cocci  taken  from  a  case  of  scarlet  fever; 
from  100  to  200  c.  c.  should  be  given  every  eight  to  twelve  hours  for  three 
or  four  days;  the  size  of  the  dose  will  depend  upon  the  age  of  the  patient. 
In  my  experience  this  serum,  if  given  at  the  proper  time,  is  a  life-saving 
measure  of  great  importance.  Escherich  and  Moser,  using  Moser's  serum, 
greatly  reduced  the  mortality  of  scarlet  fever  in  the  Annakinderspital  at 
Vienna.  Fedinski  and  Nicoll  have  also  used  antistreptococcic  serum  with 
very  favorable  results.     Collargolum  is  a  remedy  of  great  value  in  the 


TREATMENT  331 

treatment  of  the  septicopyemia  of  scarlet  fever.  It  may  be  given  in  the 
form  of  rectal  suppositories  or  perhaps  better  by  inunctions  with  unguen- 
tum  Crede.  This  latter  preparation  I  have  used  very  extensively  for  years, 
and  I  believe  that  when  properly  administered  it  is  of  great  value  in  pre- 
venting the  development  of  general  septicemia.  The  technique  for  its  use 
is  as  follows:  The  whole  upper  portion  of  the  child's  body  is  carefully 
cleansed  with  soap  and  water,  and  the  skin  is  then  made  hot  by  the  ap- 
plication of  warm  fomentations.  One-half  ounce  of  unguentum  Crede  is 
then  slowly  and  carefully  rubbed  into  the  upper  portion  of  the  child's  body 
over  the  neck,  chest,  and  axillae,  being  careful  not  to  injure  the  inflamed 
lymph  nodes.  This  should  be  done  twice  a  day  for  three  or  four 
days.  The  object  of  this  application  is  to  rub  the  silver  ointment  through 
the  skin  into  the  lymphatics  and  not  simply  to  make  an  applica- 
tion over  the  enlarged  lymph  nodes.  In  the  child  this  ointment  is  very 
readily  taken  up  by  the  lymphatics  and  acts  as  a  very  potent  lymphatic 
antiseptic. 

The  treatment  of  adenitis,  in  addition  to  the  measures  above  outlined, 
may  demand  the  local  application  of  ice;  light  ice-bags  applied  intermit- 
tently exercise  a  favorable  influence,  especially  in  the  early  stages  of  the 
inflammation.  Forchheimer  recommends  that  pressure  be  applied  to  these 
glands  by  the  application  of  flexible  collodium;  49  parts  of  collodium  to  1 
part  of  castor-oil.  If  suppuration  occurs,  poultices  are  not  only  grateful, 
but  hasten  the  breaking  down  of  the  gland,  which  is  then  to  be  incised  with 
proper  surgical  precautions. 

Otitis  Media. — Scarlet  fever  is  one  of  the  most  common  causes  of 
deafness.  In  every  case,  especially  if  there  be  a  tuberculous  family  history, 
the  physician  should  always  keep  in  mind  the  fact  that  otitis  media  may 
occur  and  may  not  only  cause  loss  of  hearing  but  may  threaten  the  life  of 
the  child  by  producing  a  mastoiditis.  The  ear  should,  therefore,  be  fre- 
quently examined  throughout  the  course  of  this  disease,  and  symptoms 
pointing  to  this  complication  should  be  constantly  watched  for.  An  early 
incision  of  the  drum  membrane  may  check  the  inflammation  and  prevent 
the  involvement  of  the  mastoid.  The  ear  should  then  be  carefully  washed 
out  twice  a  day  with  a  boric-acid  solution  and  should  be  carefully  dried  and 
some  powdered  boric  acid  dropped  into  the  meatus,  which  is  then  lightly 
plugged  with  a  pencil  of  dry  cotton;  this  treatment  should  be  continued 
from  day  to  day.  If  there  be  the  slightest  tenderness  over  the  mastoid,  an 
ice-bag  should  be  applied  to  this  region,  and  the  application  of  leeches  may 
also  be  of  value.  If,  however,  the  mastoid  tenderness  does  not  subside,  and 
the  septic  temperature  continues,  the  radical  mastoid  operation  should  be 
performed. 

Scarlatinal  rheumatism  should  be  treated  in  the  same  manner  as 
acute  rheumatic  fever.  The  joints  should  be  kept  warm  by  wrapping  them 
in  flannels  or  cottons,  and  salicylates,  such  as  aspirin,  should  be  given  to 
relieve  the  fever  and  pain.  If  the  symptoms  do  not  respond  quickly  to  the 
salicylate  treatment  it  is  to  be  discontinued,  as  there  is  some  difiEerence 


332  MEASLES,  RUBELLA,  AND  ERYTHEMA  INFECTIOSUM 

of  opinion  as  to  whether  the  continued  use  of  salicylic  acid  in  this  disease 
may  not  increase  the  dangers  of  nephritis. 

Xephritis. — In  every  case  of  scarlet  fever  the  urine  should  be  exam- 
ined daily  for  the  onset  of  this  complication,  and  if  nephritis  develops,  hot 
baths,  saline  cathartics,  a  milk  diet  and  the  other  treatment  outlined  under 
Acute  Nephritis  are  to  be  carefully  carried  out. 

Convalescence. — Scarlet  fever,  especially  in  tuberculous  children,  leaves 
the  patient  more  or  less  anemic,  with  enlarged  lymphatic  glands  and  pos- 
sibly with  an  otitis  media.  Under  such  conditions  the  organic  iron  prepara- 
tions, combined  with  malt  and  used  in  connection  witli  or  alternating  with 
cod-liver  oil,  are  of  great  value.  It  should  also  be  remembered  that  following 
severe  cases  of  scarlet  fever  some  months  are  required  for  the  heart  to  re- 
cover its  normal  tone,  and  in  those  cases  where  the  rapid  pulse  continues 
the  child  should  lead  an  outdoor  life,  but  it  should  be  carefully  supervised 
as  to  the  amount  of  exercise  it  takes. 

Septic  rhinitis,  otitis  media  and  other  septic  processes  following  scarlet 
fever  may  be  successfully  treated  by  autogenous  vaccines.  Kolmer  and 
Weston  have  used  vaccines  very  successfully  in  the  treatment  of  septic 
rhinitis,  and,  since  they  found  that  the  staphylococcus  aureus  was  the  cause 
of  this  condition  in  89  per  cent,  of  the  cases  which  they  examined,  they 
recommended  the  use  of  the  stock  vaccine  of  this  organism  when  it  is  not 
possible  to  obtain  an  autogenous  vaccine.  The  initial  dose  of  this  vaccine 
is  50,000,000,  gradually  increased  to  100,000,000  dead  staphylococci. 


CHAPTER  XL 
MEASLES,    RUBELLA,    AND    ERYTHEMA    INFECTIOSUM 

MEASLES 

Measles  is  an  acute  infectious  disease  characterized  by  fever,  catarrhal 
symptoms,  an  enanthem  and  an  exanthem. 

Etiology. — The  specific  cause  of  measles  has  not  been  discovered.  Gold- 
berg and  Anderson  produced  the  disease  in  monkeys  by  inoculating  them 
with  the  blood  of  a  measles  patient.  The  infective  microorganism  multi- 
plies rapidly  in,  and  is  readily  disseminated  from,  the  human  organism.  It 
does  not,  however,  develop  in  other  organisms  or  in  outside  culture  media. 
Measles  is  more  contagious,  and  is  desseminated  more  rapidly  in  a  suscep- 
tible community  than  any  other  acute  infection,  smallpox  and  influenza  pos- 
sibly excepted.  Its  spread,  however,  depends  in  a  large  degree  upon  rather 
close  human  intercourse ;  that  is  to  say,  by  the  well  coming  in  contact  with 
the  sick  in  homes,  schools  and  public  gatherings.  Notwithstanding  the  ex- 
treme contagiousness  of  this  disease,  it  is  not  readily  carried  from  the  sick 
to  the  well  by  a  third  party,  nor  is  the  contagion  in  any  other  manner  very 
readily  carried  long  distances.     It  may,  however,  be  disseminated  through 


MEASLES  333 

the  air  of  the  room,  and  it  is  a  recognized  fact  that  there  is  greater  diffi- 
culty in  protecting  other  susceptible  individuals  in  the  same  household  by 
rigid  quarantine  than  there  is  in  scarlet  fever  or  diphtheria.  The  conta- 
gion of  this  disease,  unlike  that  of  scarlet  fever  or  diphtheria,  has  a  short 
life  outside  of  the  human  organism,  so  that  the  room  recently  occupied  by 
a  measles  patient  soon  purifies  itself.  Measles  is  a  world-wide  disease.  It 
is  more  prevalent  during  cold  weather  because  of  the  closer  indoor  human 
intercourse  during  this  season. 

Xursing  infants  under  six  months  of  age  are  practically  immune,  but 
thereafter  the  susceptibility  increases  until,  at  the  end  of  the  first  year 
of  life,  measles  is  not  uncommon.  The  age  of  greatest  susceptibility  is 
between  three  and  seven.  During  this  period  perhaps  90  per  cent,  of  all 
children  exposed  contract  the  disease.  This  great  susceptibility  and  the 
extraordinary  contagiousness  are  the  reasons  why  such  a  small  percentage 
of  the  population  escapes.  Susceptibility  diminishes  very  slightly  with  age. 
The  chief  reason  why  measles  is  largely  a  disease  of  childhood  is  because 
most  adults  have  been  rendered  immune  by  an  attack  in  early  life.  In 
large  cities  extensive  epidemics  recur  every  two  or  three  years;  this  is  due 
to  the  fact  that  in  this  time  large  numbers  of  children  have  grown  up  to 
the  susceptible  age  since  the  last  epidemic. 

Immunity. — Natural  immunity  is  very  rare;  perhaps  not  more  than 
10  per  cent,  escape.  A  permanent  and  lasting  immunity  is  conferred  by 
an  attack  of  measles.  While  second  and  even  third  attacks  have  been  ob- 
served in  the  same  individual,  it  is  rare  indeed  to  find  instances  where  this 
acquired  immunity  does  not  protect  throughout  life.  This  protection  is 
more  marked  in  measles  than  in  any  other  of  the  acute  infections. 

Period  of  Contagion. — Measles  is  contagious  from  the  beginning  of 
the  catarrhal  stage  until  the  end  of  desquamation.  It  is  most  contagious 
during  the  height  of  the  fever  and  during  the  stage  of  eruption,  but  is 
generally  spread  by  patients  in  the  catarrhal  stage,  before  the  diagnosis 
has  been  made  and  the  quarantine  instituted.  With  the  fall  of  the  fever 
and  the  disappearance  of  the  rash  the  contagion  gradually  diminishes,  but 
probably  lasts  through  desquamation.  Ten  days  or  two  weeks  later  all 
contagion  has  disappeared,  even  though  the  sick  room  and  belongings  of 
the  patient  have  not  been  disinfected. 

Pathology. — Measles  is  rarely  a  direct  cause  of  death.  It  has,  however, 
a  comparatively  large  mortality,  due  to  complicating  conditions,  such  as 
enteritis,  pneumonia,  tuberculosis  and,  rarely,  nephritis.  Enterocolitis  and 
pneumonia  are  especially  dangerous  in  young  children.  The  pathological 
changes  belonging  to  measles  proper  are  hyperemia  of  the  skin  and  ca- 
tarrhal inflammation  of  the  mucous  membranes  of  the  respiratory  passages 
and  eyes.    Other  mucous  membranes  may  also  be  affected. 

Incubation  Period. — This  has  been  definitely  established.  The  catarrhal 
symptoms  occur  in  ten  or  eleven  days,  and  the  skin  eruption  in  fourteen 
days  from  the  date  of  exposure  to  the  contagion.  The  period  of  incubation 
is  marked  by  no  characteristic  symptoms;  certain  transitory  rashes,  such  as 


334  MEASLES,  RUBELLA,  AXD  ERYTHEMA  IXFECTIOSUM 

er}i;hema  and  urticaria,  may  appear,  but  they  are  of  little  importance,  and 
the  child  remains  well  until  the  catarrhal  symptoms  begin  to  develop  on  or 
about  the  t'leventh  day. 

Symptomatology. — The  symptoms  may  be  conveniently  divided  into 
three  stages :  the  enanthem  stage,  the  exanthem  stage  and  the  stage  of  con- 
valescence, 

Enanthem  Stage. — This  is  the  stage  of  invasion  and  commonly  lasts 
three  days.  Previous  to  the  discovery  of  the  characteristic  enanthem  of 
this  disease  by  Koplik,  a  diagnosis  during  this  stage  was  difficult  and  un- 
certain. The  onset  is  usually  marked  with  fever,  drowsiness  and  catarrhal 
symptoms  on  the  part  of  the  eyes  and  respiratory  passages.  Irritation  of 
the  throat,  coryza,  sneezing  and  a  beginning  catarrhal  irritation  of  the 
conjunctiva  are  important  symptoms,  Lacrimation  and  photophobia  are 
commonly  present,  the  patient  shielding  his  eyes  from  the  light.  The 
cough  which  accompanies  the  bronchial  catarrh  is  dry,  harsh,  and  par- 
ox}^smal,  and  if  the  larynx  be  especially  involved  in  the  catarrhal  process 
it  is  hoarse  and  croupy.  These  catarrhal  symptoms  increase  in  severity, 
the  child  becomes  more  languid,  irritable  and  uncomfortable,  and  the  fever, 
which  is  commonly  remittent  during  this  stage,  increases  from  day  to  day. 
The  appearance  of  the  above  symptom  group,  while  not  at  all  pathogno- 
monic, should  always  suggest  to  the  physician  the  possibility  of  measles.  If 
to  this  there  be  added  the  history  of  exposure  to  contagion,  a  probable 
diagnosis  can  be  made,  but  an  early  positive  diagnosis  can,  as  a  rule,  only 
be  made  by  examining  the  mucous  membrane  of  the  mouth  and  there 
observing  the  characteristic  enanthem.  This  is  best  described  by  Koplik 
himself:  "On  looking  at  the  mucous  membrane  lining  the  cheeks,  in  strong 
sunlight,  a  very  characteristic  eruption  of  irregular  stellate  or  round  rose- 
colored  spots  is  seen.  In  the  center  of  each  spot  there  is  a  bluish-white 
speck.  This  appearance  of  a  bluish-white  speck  on  a  rose-colored  back- 
ground is  pathognomonic  of  the  onset  of  measles.  The  speck  is  sometimes 
so  minute  that  strong  sunlight  is  necessary  to  render  it  visible.  The  num- 
ber of  specks  at  the  outset  may  be  less  than  half  a  dozen.  In  a  short  time 
they  become  more  numerous  and  the  rose-colored  spots  become  confluent 
so  that  there  are  diffusely  red  patches  of  buccal  mucous  membranes, 
studded  with  bluish-white  specks.  The  specks  rarely  or  never  become  con- 
fluent; their  color  does  not  resemble  that  of  sprue,  nor  are  they  as  coarse 
as  sprue  accumulations.  They  are  seen  on  the  inner  surface  of  the  lips 
and  are  sometimes  well  marked  on  the  buccal  mucous  membrane  adjacent 
to  the  gums  of  the  upper  molar  teeth.  If  the  finger  is  passed  over  the 
mucous  membrane  they  are  felt  to  be  raised  and  firmly  adherent.  They 
can  be  rubbed  off  by  force,  or  picked  off  with  forceps.  As  the  exanthema 
spreads,  the  enanthema  of  the  buccal  mucous  membrane  becomes  diffuse. 
When  the  exanthem  is  at  its  height  and  during  efflorescence  the  eruption 
on  the  mucous  membrane  begins  to  lose  its  characteristics.  The  bluish- 
white  specks  are  washed  away  by  the  buccal  secretions  and  leave  the  mucous 
membrane  diffusely  reddened  and  raw."     Koplik's  observations  as  to  the 


PLATE  in. 


B 


The  Buccal  Eruption  of  Measles  (Koplik's  Spots).    (Holt). 

A.  This  represents  the  earliest  stage;  the  spots  are  few,  rather  large,  widely  sepa- 
rated, and  usually  show  a  distinct  areola;  the  mucous  membrane  is  normal  in  color. 

B.  The  later  appearance  and  that  most  frequently  seen. 

Near  the  center  of  the  field  the  spots  are  closer  together,  although  still  remaining 
individually  distinct;  the  mucous  membrane  is  somewhat  congested.  At  the  margin 
of  the  field  they  are  fainter  and  lack  the  areola,  representing  a  still  later  period,  such 
as  is  seen  before  they  disappear  altogether,  although  in  some  cases  they  are  not  more 
distinct  than  this  at  any  stage. 


MEASLES  335 

diagnostic  value  and  prevalence  of  this  enanthem  liave  been  confirmed  by 
the  medical  world.  "Koplik  spots"  occur  before  the  appearance  of  the  skin 
eruption  in  90  per  cent,  of  the  cases.  They  may  usually  be  seen  from 
twent3'-four  to  thirty-six  hours  before  the  exanthem  appears  and  in  some 
cases  earlier.  In  a  few  instances  they  are  delayed  and  are  coincident  with 
the  skin  eruption.  It  is  important  to  remember  that  they  cannot  be  seen 
by  artificial  light,  strong  sunlight  being  necessary  for  their  detection.  Prior 
to  the  appearance  of  Koplik's  enanthem,  or  coincident  with  it,  there  may 
be  seen  on  the  velum  of  the  palate  and  on  the  mucous  membrane  of  the 
hard  palate  a  diffused  redness,  with  deeper  red  or  rose-colored  spots,  in 
the  center  of  which  are  small  white  follicles.  This  enanthem  was  described 
by  various  writers  before  Koplik  made  his  observations,  but  they  are  not 
so  characteristic  and  have  not  the  diagnostic  value  of  "Koplik  spots." 

Exanthem  Stage. — The  fever,  which,  during  the  first  three  days  of 
the  disease,  gradually  increases  in  severity,  reaches  its  height  and  con- 
tinues high  during  the  stage  of  eruption,  not  beginning  to  decline  until  the 
exanthem  is  fully  developed.  With  the  fading  of  the  exanthem  the  tem- 
perature falls  rapidly. 

The  exanthem  or  skin  eruption,  which  is  the  characteristic  symptom 
of  this  stage,  commonly  begins  about  the  fourth  day  of  the  disease  upon 
the  face  or  behind  the  ears;  it  may  first  appear  upon  the  back.  It  then 
spreads,  gradually  involving  the  neck,  chest,  back,  arms,  lower  portion  of 
the  body,  thighs,  and  lastly  the  hands  and  feet.  Two  or  three  days  are 
usually  required  for  the  eruption  to  reach  its  height,  but  in  some  instances 
it  may  spread  rapidly,  covering  the  body  within  twenty-four  hours,  and 
in  others  it  may  be  delayed,  not  reaching  its  maximum  for  four  or  five 
days.  It  appears  first  in  the  form  of  small  red  papules,  about  the  size 
of  a  pin's  head.  These  red  points,  which  may  be  readily  felt,  are  quickly 
surrounded  by  a  small  red  zone,  producing  the  typical  macule  of  measles, 
which  is  round,  oval  or  crescent  shaped,  and  is  still  separated  from  neigh- 
boring spots  by  faint  areas  of  normal  skin.  These  macules  grow  darker  in 
color  and  still  further  coalesce,  forming  darker  patches,  but  in  these  larger 
zones  of  redness  the  small,  dark-red,  hard  papules  which  formed  the  nucleus 
of  the  original  eruption  may  still  be  seen  and  felt.  However  extensive  the 
eruption  of  measles  may  become,  it  usually  maintains  its  mottled,  macular 
type,  small  areas  of  normal  skin  showing  here  and  there  throughout  the 
eruption.  The  hyperemic  character  of  this  eruption  is  shown  by  the  fact 
that  it  fades  on  pressure.  This  exanthem  is  one  of  the  most  characteristic 
of  all  eruptions,  and  when  it  occurs  in  a  typical  form  can  hardly  be  mis- 
taken for  any  other  rash.  No  description,  however,  can  present  to  the  mind 
a  very  clear  picture  of  this  or  any  other  eruption.  When  the  physician  has 
observed  the  typical  measles  exanthem  and  noted  its  characteristics  as  above 
outlined  he  will  ever  after  recognize  it.  Variations  in  the  eruption  are  not 
uncommon.  It  may,  in  rare  instances,  be  so  mild  and  evanescent  as  almost 
to  escape  attention,  and  again  it  may  rarely  occur  as  an  hemorrhagic,  pe- 
techial rash,  covering  the  entire  body.  In  this  latter  form,  known  as  "black 
23 


336  MEASLES,  EUBELLA,  AND  ERYTHEMA  IN^FECTIOSUM 


measles/'  hemorrhages  from  mucous  membranes  may  occur  and  the  dis- 
ease, especially  in  infants,  not  uncommonly  has  a  fatal  issue.  Between  the 
mild  and  the  honiorrliagic  typos  we  may  have  every  grade  of  severity,  but 
the  great  majority  of  cases  conform  to  the  ordinary  type  as  previously 
described.  With  the  spread  of  the  eruption,  all  of  the  catarrhal  symptoms 
noted  in  the  enanthem  stage  are  greatly  exaggerated.  The  conjunctival 
irritation,  photophobia,  corA'za,  bronchitis,  cough,  rapid  breathing,  fever, 
and  nervous  symptoms  are  all  increased.  Young  children  may  have  con- 
vulsions, older  ones  are  nervous,  irritable,  sleepless,  and  sometimes  deliri- 
ous. This  aggravation  in  the  symptom  group  continues  until  the  eruption 
reaches  its  height,  on  or  about  the  sixth  or  seventh  day,  when,  rather  sud- 
denly, there  is  marked  improvement  in  the  whole  symptom-complex.     The 

temperature  begins  to  fall  and  may  reach 
normal  in  one  or  two  days.  The  eruption 
fades  rapidly,  the  nervous  symptoms  dis- 
appear, and  the  child  becomes  comforta- 
ble, passing  into  a  restful  sleep ;  the  bron- 
chitis and  its  accompanying  cough  gradu- 
ally improve,  and  the  exanthem  stage  has 
been  transformed  into  the  stage  of  con- 
valescence. 

Stage  of  Convalescence. — The  stage 
of  convalescence  lasts  for  a  week  or  ten 
days.  During  this  time  the  bronchitis, 
conjunctivitis  and  other  catarrhal  symp- 
toms gradually  disappear.  The  patient's 
appetite  returns  and  he  soon  becomes  im- 
patient of  the  restraint  which  his  quaran- 
tine entails.  Desquamation  begins  with 
the  fading  of  the  eruption  and  continues 
for  a  week  or  ten  days;  it  consists  of 
small,  fine,  epithelial  scales. 

The  Blood. — During  the  preeruptive 
stage  there  is  a  marked  leukocytosis  which 
falls  to  or  below  normal  during  the  period  of  eruption.  The  polymor- 
phonuclears are  increased  during  preeruptive  and  eruptive  stages;  they 
fall  below  normal  as  the  constitutional  symptoms  subside  and  return 
to  normal  during  convalescence.  The  small  lymphocytes  are  decreased 
during  the  height  of  the  toxemia  and  increased  as  the  symptoms  begin  to 
subside.  The  large  mononuclears  are  increased  late  in  the  disease.  The 
eosinophiles  are  decreased  early  in  the  attack  and  increased  later. 

The  Urine. — The  urine  during  the  febrile  stage  is  scant,  highly  colored 

and  may  contain  traces  of  albumin.     Acute  Bright's  disease,  however,  is  a 

very  rare  complication.    The  diazo-reaction  occurs  in  nearly  every  case  of 

measles  (80  to  90  per  cent.).    Acetone  and  diacetic  acid  may  be  founfl. 

Complications. — Broncliopneumonia  is  the  most  common  and  the  most 


DAY 
OF  MONTH 

26 

27 

28 

29 

30 

31 

OAV 
OF  DISEASE 

1 

2 

3 

4 

5 

6 

7 

107 
106' 
105° 

g   104° 

3 

£   103' 

a 

u   102° 

u   101 

z 

§   100 

99° 

98° 

97° 

/ 

^ 

^ 

N 

/ 

A 

J 

\ 

\ 

iu 

A 

V 

\ 

PULSE 

§ 

s 

2 

2 

2 

o 

ff- 

2 

£ 

a 

s 

£ 

O 

RESPIRATION 

s 

s 

g 

g 

g 

S 

S 

S 

5 

s 

s 

s 

£ 

FiQ.  65. — Measles  Uncomplicated. 


MEASLES 


337 


dangerous  of  all  complications.  It  occurs  most  frequently  in  hospital 
wards,  where  staphylococci,  streptococci  and  pneumococci  abound,  and  is 
seen  most  commonly  in  children  under  four  years  of  age;  it  is  at  this 
time  of  life  that  bronchopneumonia  is  so  dangerous.  Henoch  says  that 
every  fatal  case  of  measles  shows  some  pneumonia.  Lobar  pneumonia^  due 
to  a  complicating  pneimiococcus  infection,  is  not  uncommon  in  older  chil- 
dren, but  the  prognosis  in  this  condition  is,  on  the  whole,  favorable.  Mem- 
branous laryngitis  may  be  a  complication  of  measles.  In  some  instances 
this  pseudo-membrane  may  be  produced  by  cocci,  but  for  clinical  reasons 
it  is  safe  to  assume  that  it  is  always  diphtheritic.  While  membranous 
laryngitis  is  rather  an  uncommon  complication  of  measles,  a  severe  spas- 
modic, catarrhal  laryngitis,  producing  pronounced  croupy  symptoms,  is  not 


0*Y 
OF    MONTH 

26 

27      28 

29      30 

31 

1       2 

3      4 

s 

5       7 

8 

9 

10 

II      12 

13 

14 

or  DISEASE 

1 

2       3 

4        5 

6 

7       8 

9      10 

II     1 

2      13 

14 

15 

16 

17      18 

19 

20 

107 
106'^ 
105' 
S    104'= 

K 

a 

5    102' 

k- 

I  .or 

X 

z 

a    100° 

r 
< 
u 

99 

98 

97' 

f\ 

1 

h 

ft 

M 

A 

A 

h  1 

/ 

5r 

r 

h 

ft 

1 

L, 

V 

( 

^ 

l^ 

N 

i 

s 

I'A 

1 

V 

\ 

1 

r 

,/ 

■^T 

\J 

'^7 

1     ^ 

J 

11 

/ 

[   V 

1 

r 

POISE 

z 

t. 

s 

7.  %  i 

5  ;  :  ? 

: ; 

z 

§  S  £  : 

^  I  B 

°  S:  S 

£   £    i 

:  z 

ck  2 

i  s  ; 

'  S  i  I 

1 

S 

« 

RESPIRATION 

g 

s 

s 

S  g  s 

s  s  S  2 

^    « 

; 

g  ;  s  s 

:  ;  s  s 

;  s  2 

Si; 

o  . 

S  S 

;  :  : 

,  2  s  : 

.  2 

I 

s 

Fig.  56. — Measles  Complicated  by  Bronchopneumonia. 

at  all  uncommon.  Tuberculosis  is  perhaps  after  all  the  most  important 
complication  of  measles.  In  the  chapter  on  Tuberculosis  the  remarkable 
prevalence  of  lymph-node  tuberculosis  is  dwelt  upon.  The  majority  of 
children  entering  public  hospitals  have  bronchial  lymph-node  tuberculosis, 
and  this  is  one  of  the  explanations  for  the  frequency  of  bronchopneumonia 
;imong  this  class  of  patients.  A  large  percentage  of  the  bronchopneu- 
monias occurring  as  a  complication  of  measles  is  tuberculous,  hence  the 
importance  of  recognizing  the  fact  that  measles,  which  irritates  the  bron- 
chial IjTnph  nodes,  is  a  disease  especially  liable  to  develop  a  latent  into  an 
active  tuberculosis.  General  miliary  and  meningeal  tuberculosis  are  not 
uncommon  sequels  of  measles,  and  tuberculous  pleurisy  and  empyema  may 
occur. 


338  MEASLES,  RUBELLA,  AND   ERYTHEMA  INFECTIOSUM 

Measles  may  irritate  and  inflame  the  mucous  membrane  of  the  gas- 
trointestinal canal,,  in  some  instances  causing  a  violent  enterocolitis.  This 
complication  occurs  especially  in  young  children  and  may  be  serious,  even 
fatal.  Aphthous  stomatitis  and  thrush  may  occur  in  young  children,  and 
their  importance  is  increased  by  the  fact  that  they  must  be  differentiated 
from  the  enanthem  of  measles.  Conjunctivitis,  one  of  the  catarrhal  symp- 
toms of  measles,  may  become  aggravated  and  produce  corneal  ulcerations 
and  inflammations  of  the  lacrimal  glands.  Pemphigoid  cutaneous  erup- 
tions are  rare  and  interesting  complications,  noted  by  many  writers,  but 
do  not  mean  an  unfavoral)le  prognosis.  Measles  may  also  be  associated 
with  whooping-cough,  scarlet  fever  and  diphtheria.  These  mixed  infec- 
tions usually  occur  in  institutions.  The  combination  of  whooping-cough 
and  measles  frequently  results  in  a  fatal  bronchopneumonia;  diphtheria 


OF  SoNTH    '0  21  ?2  23  24  75  26  ?7  28  29  30  31    1  1  2    3    4    5    6    7     8    9    10   II   12  13  14   15  16   17   I8|  I9|20  2l'2: 

OForsEAse    1     2    3    4    5    6     7     8    9    10   II   12  13  14   15  16  17   18  19  20  21  22  23  24  ^5  26  27  28  29  30  31  32  33p< 

107^                                                     

URE 

1   ,r-U-UV-.^V--f, --  

1  z>      y....\ - 1 

a  '02                                        .                v^ 

S     ,on» I ll _-l tl.-i 

S      qo'i M     .,     ,!^5_     ^,_.i___U-,.i     -.-        .     L,^_,_-^4___i_Z_JL_S 

X  '" ::::::::::::::::!_  .tA.:^isj.t.—i.tit'^  ___  J..^::z."i:  v_::^:2 

5   oe»::i:iiiiii:ii:::ii:S-iiiii-Zi .„ t_ii__i 2_5;:l::S.iiiiii_;. 

gj ^      

FiQ.  57. — Measles  Complicated  by  Bronchopneumonla. 


and  measles  commonly  mean  membranous  croup;  scarlet  fever  and  measles 
may  cause  a  septicopyemia. 

Prognosis. — The  prognosis  of  uncomplicated  measles  in  private  practice 
is  very  good;  nearly  all  such. cases  recover.  In  institutions  it  is  very  dif- 
ferent; the  death  rate  here,  on  account  of  the  prevalence  of  dangerous 
complications,  may  be  very  high.  Age  is  a  most  important  prognostic 
factor.  Holt  places  the  mortality  of  this  disease  under  two  years  of  age 
at  20  per  cent.,  while  the  total  mortality  is  only  about  5  per  cent.  The 
prognosis  is  also  influenced  by  the  character  of  the  epidemic.  If  the  disease 
is  prevailing  in  an  unusually  severe  or  malignant  form  the  prognosis  is 
much  graver  than  it  is  iu  ordinary  epidemics.  The  previous  condition  of 
the  child,  especially  the  presence  of  lymph-node  tuberculosis,  greatly  in- 
creases the  danger.  The  various  complications  previously  noted  add  a 
gravity  to  the  disease  which  belongs  to  the  complication  and  not  to  the 
measles. 

Prophylaxis. — It  is  of  the  very  greatest  importance  that  young  and 
tuberculous  children  should  be  protected  from  the  contagion  of  measles. 


MEASLES  339 

To  accomplish  this  a  rigid  quarantine  should  be  instituted.  If  these  two 
classes  of  children  can  be  protected  until  they  are  older,  they  will  be  in  a 
much  better  physical  condition  to  withstand  this  disease.  The  laity,  how- 
ever, cannot,  as  a  rule,  be  brought  in  sympathy  with  rigid  quarantine  meas- 
ures in  measles.  They  argue  with  some  degree  of  truth  that  the  child  must 
have  it  some  day  and  why  not  now,  when  it  can  be  properly  cared  for. 
Whether  or  not  the  physician  takes  this  view  of  the  case  with  the  normal 
healthy  child  over  four  years  of  age,  there  is  no  question  as  to  his  re- 
sponsibility in  the  matter  of  protecting  the  very  young  and  the  tuberculous, 
and  in  all  instances  it  is  his  duty  to  insist  upon  a  quarantine  that  will  at 
least  protect  people  outside  the  family.  The  young  and  tuberculous  are 
better  protected  by  sending  them  away  from  home  when  it  is  not  possible 
to  send  the  patient  away.  Following  convalescence,  the  sick  room  and  all 
of  its  belongings  should  be  disinfected  with  formaldehyde  and  thoroughly 
ventilated  and  cleaned.    This  effectively  destroys  the  contagion. 

Treatment. — Measles  is  a  self-limited  disease  for  which  we  have  no 
specific  medication.  Treatment  should  therefore  be  directed  to  the  relief 
of  uncomfortable  symptoms  and  the  avoidance  of  complications.  The  pa- 
tient should  be  put  to  bed  and  kept  there  until  convalescence  is  established. 
The  bedroom  should  be  well  ventilated  and  kept  at  a  temperature  of  about 
70°  F.  Sudden  chilling  of  the  surface  of  the  body  by  great  variations  in 
the  temperature  of  the  room,  or  by  draughts  of  cold,  air,  or  baths  with 
cold  water,  are  to  be  avoided.  The  patient  should  be  sponged  off  with 
warm  water  once  a  day,  and  afterwards  rubbed  with  lanolin  or  oil.  If  he 
complains  of  itching,  carbolic  acid  may  be  added*  to  the  lanolin.  The  room 
may  be  sliglitly  darkened,  but  light  should  not  be  excluded.  The  patient's 
eyes,  especially  if  he  suffers  from  photophobia,  may  be  shaded. 

The  DIETETIC  TREATMENT  is  important,  especially  in  young  children. 
All  children  under  three  years  of  age  should  be  fed  during  the  onset  of  the 
disease  as  though  they  had  an  enterocolitis.  Barley  water,  broth,  diluted 
skimmed  milk,  and  peptonized  milk  are  among  the  foods  especially  suitable 
to  ward  off  gastrointestinal  complications.  In  older  children  a  light,  simple 
diet,  having  milk  for  its  basis,  should  be  employed  during  the  acute  stage. 
A  moderate  amount  of  cool  water  may  be  taken,  and  where  the  throat 
symptoms  are  especially  irritable  small  bits  of  ice  in  the  mouth  are  per- 
missible. The  prejudice  of  the  laity  against  cold  drinks  and  cold  baths 
may,  to  a  certain  extent,  be  respected  without  inflicting  great  punishment 
on  the  patient;  but  the  hot  bedroom,  hot  drinks  and  heavy  bed  clothing, 
for  the  purpose  of  "bringing  out"  the  eruption,  are  superstitions  which  may 
be  resisted,  greatly  to  the  comfort  of  the  patient. 

Symptomatic  Treatment. — The  cough  and  bronchial  irritation  usually 
require  treatment.  In  younger  children  the  bromid  of  potash  or  soda, 
combined  with  small  doses  of  belladonna,  put  up  in  essence  or  elixir  of 
pepsin,  usually  allays  the  cough;  if  this  does  not  suffice,  small  doses  of 
chloral  may  be  added  to  this  mixture.  In  older  children  it  may  be  ad- 
visable to  control  the  irritable  cough  with  small  doses  of  codein  or  pare- 


340  MEASLES,  RUBELLA,  AND  ERYTHEMA  INFECTIOSUM 

goric,  but  it  should  be  remembered  that  these  opiates  are  in  no  sense  cura- 
tive and  their  effect  should  therefore  be  carefully  studied;  if  they  benefit 
the  patient  more  than  they  do  him  harm,  they  may  be  continued.  These 
drugs  produce  constipation  and  interfere  to  a  certain  extent  with  the  ap- 
petite and  digestion.  Syrups  and  expectorants  should  never  be  used.  I  do 
not  believe  any  good  whatever  can  result  from  the  syrup  of  ipecac,  syrup 
of  squills  and  ammonia  preparations  commonly  used,  and  I  know  that  they 
may  do  much  harm  by  disturbing  the  appetite  and  digestion.  They  should 
at  least  never  be  given  to  young  children.  The  fever  and  nervous  symp- 
toms may  be  controlled  by  sponging  with  lukewarm  water,  and  by  the  giv- 
ing of  antipyrin,  aspirin  and  phenacetin  in  doses  suited  to  the  age  of  the 
child.  I  do  not  believe  any  harm  whatever  results  from  the  use  of  anti- 
pyrin associated  with  tincture  of  strophanthus  and  combined  in  a  suitable 
elixir,  and  I  do  believe  that  this  prescription,  when  given  in  proper  doses 
to  suit  the  age  of  the  child,  will  very  materially  relieve  the  distressing 
symptoms  and  thereby  add  to  the  comfort  of  the  patient,  during  both  the 
enanthem  and  exanthem  stage  of  this  disease.  The  following  prescription 
may  be  used : 

]5     Antipyrin    3  gg 

Tinct.   strophanthus    3  ss 

Tinct.  belladonnae   3  ss 

Elixir  lactated  pepsin  ad 5  iii 

Teaspoonful  every  four  hours  for  a  child  four  years  of  age. 

If  lung  complications'  develop,  guaiacol  inunctions  and  carbonate  of 
guaiacol  internally  should  become  a  part  of  the  routine  treatment.  With 
the  onset  of  septic  symptoms  and  especially  pneumonia,  the  guaiacol  oint- 
ment is  changed  for  unguentum  Crede  and  a  number  of  doses  of  antistrep- 
tococcic serum  given,  as  outlined  in  the  treatment  for  scarlet  fever.  In 
older  children  inhalations  of  creosote  and  oil  of  eucalyptus  may  be  used  as 
a  bronchial  antiseptic,  and  to  relieve  the  symptoms  resulting  from  respira- 
tory irritation.  No  medicines  are  necessary  to  bring  out  the  eruption, 
but,  in  cases  where  it  has  failed  to  come  out  properly  and  a  hroncJio- 
pneumonia  is  threatening  or  has  already  begun,  warm  mustard  baths  may 
be  of  value  in  increasing  the  peripheral  circulation  and  relieving  the  pul- 
monary congestion.  These  cases  may  also  be  benefited  by  applications  of 
warm  camphorated  oil  applied  under  an  oil  silk  jacket,  as  outlined  in  the 
Treatment  of  Bronchopneumonia.  Cathartics  are  to  be  used  cautiously 
in  the  treatment  of  measles.  Enemata  commonly  suffice  to  keep  the  bow- 
els open;  when  necessary,  however,  a  mild  cascara  laxative  may  ])e  used. 
If  enteritis  threatens  castor  oil  should  be  given  and  the  patient  placed  on 
the  diet  outlined  under  Enterocolitis.  Pneumonia,  tuberculosis,  mem- 
branous laryngitis  and  other  complications  are  to  be  treated  as  elsewhere 
noted.  In  membranous  laryngitis  it  is  always  safest  to  administer  diph- 
theria antitoxin,  even  though  there  may  be  a  possibility  that  the  pseudo- 
membrane  is  produced  by  cocci.     The  eyes  should  be  properly  protected 


RUBELLA  341 

during  convalescence,  and  their  use  for  reading  and  other  close  work  should 
be  prohibited  until  all  traces  of  conjunctivitis  have  disappeared. 


RUBELLA 

{Roiheln,  German  Measles) 

Eubella  is  an  acute  infectious  disease  in  no  way  related  to  ordinary 
measles.  It  is  characterized  by  slight  fever,  enlargement  of  the  post- 
cervical  lymph  nodes  and  by  a  rash  resembling  in  some  particulars  both 
that  of  measles  and  scarlet  fever. 

Etiology. — Breast-fed  babies  under  six  months  of  age  are  practically 
immune.  During  the  latter  half  of  the  first  year  of  life  the  susceptibility 
to  this  disease  gradually  increases.  From  that  time  on  nearly  every  in- 
dividual is  susceptible.  Age  does  not  confer  immunity.  Adults  and  chil- 
dren alike  nearly  always  contract  the  disease  when  they  come  in  close  con- 
tact with  the  infection.  Epidemics  are  much  more  common  during  the 
winter  months. 

The  specific  microorganism  of  rubella  is  unknown,  and  like  the  con- 
tagious principle  of  measles  it  is  short-lived  after  it  leaves  its  host.  The 
contagion  does  not,  for  any  length  of  time,  cling  to  and  contaminate  the 
clothes,  bedding  and  other  belongings  of  the  patient.  It  is  spread  by  the 
well  coming  in  contact  with  the  sick;  rather  close  contact  is  necessary. 
There  is  little  or  no  danger  of  a  third  party  carrying  the  contagion  from 
the  sick  to  the  well.  The  infection,  however,  may  be  carried  short  dis- 
tances through  the  air  and  by  fomites.  There  is  great  variability  in  the 
contagiousness  of  this  disease  in  different  epidemics.  The  period  of  con- 
tagion begins  a  day  or  two  before  the  eruption  appears  and  lasts  until  it 
disappears. 

Immunity. — One  attack  confers  immunity;  second  attacks  are  very 
infrequent.  An  attack  of  this  disease  does  not  afford  protection  from 
measles  or  scarlet  fever,  nor  do  these  diseases  protect  the  patient  from 
rubella.  Eubella,  measles  and  scarlet  fever  may  follow  each  other  in 
rapid  succession  as  house  epidemics  in  the  same  family. 

Incubation. — The  period  of  incubation  varies  from  ten  to  twenty  days. 
Griffith  reports  a  case  where  it  was  one  day.  It  would  appear,  therefore, 
that  the  incubation  period  is  either  very  variable,  or  that  more  accurate 
observations  are  necessary  to  establish  its  limits. 

Symptomatology. — The  onset  is  commonly  mild.  The  rash  may  be 
the  first  symptom  noted.  It  may  be  accompanied  or  preceded  by  a  slight 
elevation  of  temperature,  a  feeling  of  general  malaise,  headache  and  back- 
ache. There  may  be  mild  catarrhal  symptoms,  such  as  slight  pharyngitis, 
coryza  and  infection  of  the  conjunctiva.  A  slight  cough  and  gastric 
disturbance  may  be  present.  The  fever  does  not  run  high.  In  some  in- 
stances it  may  scarcely  be  above  normal.  In  severe  cases,  especially  in 
young  children,  it  may  reach  103  °F.    Its  maximum  is  commonly  attained 


342  MEASLES,  EUBELLA,  AND  ERYTHEMA  INFECTIOSUM 

within  the  first  thirty-six  or  forty-eight  hours,  and  it  then  subsides.  There 
is  nothing  at  all  characteristic  in  the  fever,  pulse,  or  respirations. 

The  ENANTHEM  of  this  disease  is  always  present  and  is  a  valuable  aid 
in  differentiating  it  from  other  acute  infections.  Forchheimer  says  of  this 
enantheni:  "It  consists  of  a  macular,  distinctly  rose-red  eruption,  upon 
the  velum  of  the  palate  and  uvula  extending  to,  but  not  on,  the  hard 
palate.  The  spots  are  arranged  irregularly,  not  crescentically,  of  the  size 
of  large  pin-heads,  very  little  elevated  above  the  mucous  membrane,  and 
do  not  seem  to  produce  any  reaction  upon  it."  The  enanthem  appears 
just  before  or  simultaneously  with  the  exanthem  or  skin  eruption,  and 
lasts  one  or  two  days.  The  whole  mucous  membrane  of  the  throat,  espe- 
cially the  pharynx,  is  red  and  congested. 

The  EXANTHEM^  or  skin  rash,  is  of  special  value  in  diagnosis  when  it 
is  associated  with  Forchheimer's  enanthem.  The  skin  rash  in  and  of  itself 
is  very  puzzling  from  a  diagnostic  standpoint,  because  of  its  variations.  It 
commonly  appears  as  small,  pale  rose-red  spots  somewhat  smaller  than 
the  measles  macule.  This  rash,  however,  resembles  to  a  certain  extent  the 
measles  eruption,  but  is  lighter  in  color.  These  macules  may  coalesce  as 
in  measles,  forming  patches  of  rose-red  colored  skin.  In  other  instances 
the  rash  may  occur  as  fine,  red  points  producing  more  or  less  uniform 
redness  of  the  skin.  This  type  of  the  eruption,  therefore,  more  closely  re- 
sembles the  exanthem  of  scarlet  fever.  It  has  not,  however,  the  scarlet 
hue  and  can  usually  be  differentiated  from  scarlet  fever  by  the  rose  tint 
and  less  punctate  form  of  the  rash.  Both  forms  disappear  on  pressure. 
In  some  cases  the  two  eruptions  occur  in  the  same  patient;  on  one  por- 
tion of  the  body  the  macular  measles-like  eruption  predominates,  and  on 
another  the  uniform  rose  tint,  somewhat  resembling  scarlet  fever,  may  be 
seen.  The  exanthem  begins  on  the  face  and  spreads  downward,  involving 
the  neck  and  body  and  lastly  the  arms  and  legs.  A  point  of  diagnostic 
importance  is  that  the  eruption,  unlike  that  of  scarlet  fever,  appears  on 
the  lips  close  around  the  mouth.  Another  point  of  great  diagnostic 
importance  is  that  the  rash,  unlike  those  of  measles  and  scarlet  fever, 
appears  on  the  first  day  of  the  disease,  reaches  its  maximum  by  the 
second  day,  and  then  begins  to  fade.  It  may  entirely  disappear  in 
one  or  two  days,  or  traces  of  it  may  linger  for  a  week  or  ten  days. 
The  severity  of  the  disease  is  not  measured  by  the  length  of  time  the 
rash  continues.  It  may  disappear  and  again  return;  this,  however,  is  very 
uncommon. 

The  IRRITATION  OF  LYMPHATIC  TISSUES  is  vciy  characteristic  of  this 
disease.  The  spleen  in  almost  every  instance  is  slightly  enlarged,  and  can 
be  palpated.  Enlargement  of  the  posterior  cervical  lymph  nodes  is  a 
constant  and  distinctive  feature,  since  they  are  not  so  uniformly  enlarged 
in  any  of  the  other  acute  infections.  The  nodes  in  the  neck  most  com- 
monly enlarged  are  the  post-cervical,  the  suboccipital  and  the  post-auricu- 
lar. The  anterior  cervical  nodes,  however,  may  also  be  enlarged  and  the 
superficial  lymph  nodes  throughout  the  body  can  commonly  be  felt. 


ERYTHEMA  INFECT  J  OSUM  343 

The  BLOOD  shows  a  polyniiclear  leukocytosis  during  incubation  and 
leukopenia  during  the  stage  of  eruption. 

The  Urine. — The  diazo-reaction,  which  is  so  constantly  present  in 
measles,  is  absent  in  this  disease. 

Complications. — The  lighting  up  of  a  latent  tuberculosis  is  the  most 
common  complication  of  rubella.  Other  complications  are  rare.  In  the 
more  severe  cases  gastrointestinal  and  respiratory  diseases  may  occur. 

Prognosis. — This  is  good.  Fatalities  have  been  reported  in  epidemics 
of  extreme  severity. 

Treatment. — The  patient  should  be  isolated  until  a  positive  diagnosis 
has  been  made.  It  is  a  matter  of  serious  import  to  mistake  a  mild  scar- 
latina for  rubella.  The  diagnosis  once  established,  the  disease  is  so  simple 
as  not  to  require  a  rigid  quarantine.  Patients,  however,  should  be  confined 
to  their  homes,  so  as  to  prevent  spreading  the  disease.  , 

The  average  patient  requires  no  medical  treatment.  In  the  more  se- 
vere cases  a  mild  laxative  should  be  given,  and  the  patient  confined  to 
bed  for  one  or  two  days.  Small  doses  of  antipyrin  and  phenacetin  may 
be  given  to  relieve  the  fever  and  nervous  symptoms. 


ERYTHEMA  INFECTIOSUM 

Erythema  infectiosum  is  an  acute  infectious  disease  first  described  by 
Escherich.  It  is  characterized  by  a  rose-red  rash  with  slight  or  no  con- 
stitutional symptoms. 

Etiology. — This  disease  is  believed  to  be  rare  in  America,  although  in 
recent  years  small  epidemics  have  been  observed  in  our  larger  cities. 
Infants  under  one  year  of  age  are  immune.  Older  children  are  commonly 
affected,  and  adults  are  susceptible.  It  usually  occurs  in  epidemics.  The 
specific  organism  is  unknown.  It  is  spread,  however,  by  contagion, 
rather  close  contact  being  necessary,  and  it  is  in  no  way  related  to  rubella, 
scarlet  fever  or  measles. 

Symptomatology. — After  an  incubation  period  of  ten  or  twelve  days  an 
erythematous  eruption  may  appear  on  the  face.-  This  rather  brilliant  red 
rash  spreads  over  the  cheeks  onto  the  body.  Parts  of  the  skin,  however,  • 
are  commonly  normal  in  color,  giving  the  eruption  a  blotchy  appearance. 
It  is  a  typical  erythema,  having  much  the  appearance  of  erysipelas,  except 
that  the  skin  is  not  inflamed  as  in  that  disease.  The  exanthem  lasts  for 
about  one  week,  gradually  fading,  and  is  not  followed  by  desquamation. 
The  patient  may  suffer  from  slight  headache  and  sore  throat.  The  tem- 
perature rarely  rises  above  100  °F.,  so  that  this  condition  is  practically 
an  afebrile  disease.  The  lymphatic  tissues  are  not  involved  as  they  are 
in  rubella. 

Prognosis. — This  is  always  good,  and  no  treatment  is  required. 

The  following  table  from  Ruhrah  will  assist  in  the  differentiation  of 
the  acute  exanthemata : 


344     MEASLES,  RUBELLA,  AND  ERYTHEMA  INFECTIOSUM 


Differential  Diagnosis  of  Rubella,  Scarlet  Fever,  Measles  and  Erythema 

Infectiosum 


Contagion 


Incubation. 
Prodromes. 

Koplik  spots. 

Vomiting. 
Fever. 


Catarrhal  symptoms 
Tongue. 

Throat. 


Diarrhea. 
Lymph  nodes. 


Pulse. 

Albuminuria. 

Eruption. 


Desquamation. 
Convalescence. 


RnBELLA 


Apparently  varies  in 

epidemics. 
Direct  contact. 
Possibly  from  fomi- 

tes,  not  through  the 

air. 
Variable    average    1 

to  3  weeks. 
Slight   and  of  short 

duration. 
Occasionally    a    day 

or  two  of  malaise. 
None. 

Rare. 

Slight — average  1  to 
2  days,  sometimes 
for  4  days,  seldom 
more  than  101°  to 
102°. 

Slight. 

Slight  coat,  nothing 
characteristic. 

Small,  punctiform, 
red  spots  over 
uvula  and  palate 
Pharynx  slightly 
reddened. 

General  enlargement 
especially  of  post- 
cervical  nodes. 


Varies  with  fever. 

Rare  and  slight. 

Begins  on  face, 
spreads  to  neck  and 
breast,then  to  arms, 
legs  and  feet.  Is  fad- 
ing from  older  parts 
while  spreading  to 
new.  Two  forms 
—  common  form, 
morbilliform,  small, 
slightly  elevated 
papules,  discrete, 
sometimes  con- 
fluent; more  rarely 
scarlatiniform,  lasts 
2  to  4  days  or  less, 
color  rose-red  but 
this  varies. 


Measles 


Slight  and  branny. 

Rapid,  no  complica- 
tions. 


Highly  contagious. 
By  direct  contact. 
By  fomites. 
Through  the  air. 


Average  9  to  14  daj-s, 

3  to  4  days. 
Drowsiness  and   ca- 
tarrhal symptoms. 

Present  in  90  or  95 
per  cent,  of  cases. 

Occasional. 

Marked  high  curve 
lasting  about  a 
week,  average  from 
102°  to  104°. 

Marked. 

Tongue  coated,  that 
of  any  fever. 

Moderate  pharyn- 
gitis and  redness  of 
mucous  membranes 


Frequent. 

Postcervical,  post- 
auricular,  and  sub- 
maxillary nodes  en- 
larged. 

Varies  with  fever. 

Rare. 

Begins  on  face, 
spreads  gradually 
over  entire  body, 
covering  it  by  the 
second  or  third  day. 
Consists  of  small 
papules  arranged  in 
crescentic  groups; 
these  are  confluent 
in  places.  Lasts 
4  to  5  days.  Is 
deep  red,  often  pur- 
plish. 


Branny. 

Slow,  frequent  com- 
plications, as  pneu- 
monia. Later  other 
infectious  diseases, 
as  tuberculosis. 


SCABLET 

Fever 


Marked. 

By  direct  contact. 

By  fomites. 


Average  1  to  6  days. 

Short  or  wanting — 
onset  usually  sud- 
den. 

None. 

Common. 

High  fever  lasting 
about  a  week,  aver- 
age 104°  to  105°. 


Absent. 
Strawberry,      later 

mulberry  tongue. 
Usually      a      severe 

angina. 


Depends  on  extent 
of  throat  involve- 
ment, glands  at 
angle  of  the  jaw 
involved. 

Ver>'  rapid 

Common. 

Begins  on  neck  and 
chest,  spreads  slow- 
ly over  entire  body 
— maximum  about 
the  fourth  day. 
Does  not  affect  lips. 
Consists  of  small, 
punctate  spots  or  a 
diffuse  blush;  dis- 
appears on  pres- 
sure; lasts  about  a 
week.  Intense  red 
color. 


Marked  in  flakes  and 
large  pieces. 

Slow,  complications 
frequent,  as  nephri- 
tis, otitis  media, 
etc. 


Erythema 
Infectiosum 


Feeble. 

Usually    by    direct 
contact. 


Average    6    to    14 

days. 
Very  slight  and  of 

short    duration. 


None 


Uncommon. 
Little  or  none. 


None. 

Sometimes  slightly 

coated. 
Sometimes        very 

slight  sore  throat 

at  onset. 


Not  enlarged. 


Normal. 

None. 

First  on  face  as 
symmetrical,  rose- 
red  blush,  for  the 
most  part  sharply 
defined  and  re- 
sembling erysipe- 
las. It  is  hot  to 
the  touch  but  not 
sensitive  and  it 
does  not  itch.  The 
second  day  it 
spreads  to  the 
body  and  extremi- 
ties, small  discrete 
crescentic  patches 
over  the  body  and 
sparingly  on  the 
inner  and  flexor 
surfaces  of  limbs. 
Marked  map-like 
eruption  on  outer 
and  extensor  sur- 
faces. Begins  to 
fade  on  face  in  4 
or  5  days.  Lasts 
altogether  6  to  10 
days. 

None. 

Rapid,  no  complica- 
tions. 


VARIOLA  345 


CHAPTER  XLI 
VARIOLA,    VACCINIA    AND    VAEICELLA 

VARIOLA 

Variola,  or  smallpox,  is  an  acute  infectious  and  highly  contagious 
disease  characterized  by  more  or  less  severe  constitutional  symptoms  and 
by  a  specific  eruption  passing  through  the  stages  of  papule,  vesicle,  pus- 
tule, scab  and  scar.  The  disease  has  no  peculiar  manifestations  in  child- 
hood, running  much  the  same  course  at  all  ages.  Before  the  days  of  vac- 
cination the  disease  was  almost  confined  to  childhood,  90  per  cent,  of  the 
cases  occurring  in  children  under  ten  years  of  age.  The  immunity  of 
adults  during  that  period  was  due  to  the  fact  that  a  vast  percentage  of 
the  adult  population  was  immune  from  having  had  the  disease.  At  the 
present  time,  however,  by  reason  of  the  fact  that  nearly  all  children  are 
vaccinated,  the  disease  is  rarely  seen  in  childhood.  It  is  now,  therefore,  in 
ci\'ilized  communities,  a  comparatively  rare  disease  confined  almost  ex- 
clusively to  adults,  among  whom  the  immunity  which  resulted  from  early 
vaccinations  has  wholly  or  partially  expired.  The  disease  is  so  infrequent 
at  the  present  time  that  it  is  rarely  seen  in  private  practice.  Many  physi- 
cians with  a  long  and  active  medical  career  have  never  come  in  contact 
with  it. 

Etiology. — The  specific  microorganism  of  smallpox  is  now  believed  to 
be  the  ^'Cytoryctes  Variolae,"  a  parasitic  protozoa,  first  clearly  described  by 
Guanieri  in  1892,  and  subsequently  shown  to  be  etiologically  related  to 
this  disease  by  Councilman  and  his  associates. 

ContagioTisness. — It  is  the  most  highly  contagious  of  all  infectious 
diseases,  being  spread  directly  by  contact  of  the  sick  with  the  well,  and 
indirectly  by  the  contagion  being  carried  by  a  third  party,  and  by  clothing, 
bedding,  and  other  belongings  of  the  sick  room.  The  contagion  is  given 
off  from  the  lungs,  and  by  the  discharges  from  the  vesicles  and  pustules 
of  the  skin  eruption.  The  dry  crusts  may  carry  and  transmit  the  disease 
long  distances.  It  is  believed  that  it  may  be  transmitted  through  the  air 
for  distances  sufficient  to  make  house  to  house  contamination  possible. 
The  contagion  lasts  from  the  beginning  to  the  end  of  the  disease,  but  is 
very  slight  until  the  skin  eruption  appears.  Race  and  sex  offer  no  bar- 
riers to  its  dissemination.  The  cold  winter  months  furnish  conditions 
favorable  to  its  spread.  Age  does  not  confer  immunity,  but  children  are 
slightly  more  susceptible  than  adults. 

Incubation. — Smallpox  has  a  very  definite  period  of  incubation;  this 
is  usually  ten  to  twelve  days,  and  it  is  believed  that  its  limits  are  from 
five  to  twenty  days. 

Symptomatology. — The  Stage  of  Invasion. — The  onset  is  marked  by 
very  pronounced  symptoms.    Headache,  backache,  convulsions,  gastric  dis- 


346  VARIOLA,  VACCINIA,  AXD  VARICELLA 

turbance  and  profound  depression  are  present  in  typical  cases.  In  older 
children  and  adults  a  chill  takes  the  place  of  the  convulsion.  There  may 
be  great  variation  in  the  severity  of  this  initial  symptom  group.  Occasion- 
ally severe  cases  have  a  mild  onset,  but,  as  a  rule,  the  initial  toxemia  is 
pronounced;  this  is  especially  so  in  unvaccinated  children  in  whom  the 
nervous  system  is  profoundly  aifected.  Not  infrequently  convulsions,  stu- 
por, coma,  delirium  and  profound  depression  occur.  The  stage  of  inva- 
sion lasts  for  about  three  days,  during  which  time  severe  backache  in  the 
lumbar  region  is  a  rather  characteristic  symptom,  and  the  headache  may 
continue  to  be  so  severe  that  therapeutic  measures  are  required  for  its 
relief.  The  initial  vomiting  may  not  be  repeated,  but  loss  of  appetite  and 
gastric  discomfort  are  present.  The  fever  rises  rapidly  with  the  initial 
chill;  it  may  reach  104°  or  105°F.  within  the  first  twenty-four  or  thirty- 
six  hours.  It  usually  reaches  its  highest  point  on  the  second  or  third  day, 
and  then,  in  the  less  severe  cases,  falls  rapidly  to  normal,  and  even  in 
severe  cases  there  is  a  sharp  fall  in  temperature.  After  this  fall  there 
may  be  only  a  slight  elevation  of  temperature  during  the  next  few  days, 
when  there  is  a  secondary  rise  coincident  with  the  formation  of  pustules. 
This  septic  or  secondary  fever  continues  for  a  number  of  days,  during 
the  pustular  stage,  and  then  falls  to  normal  as  convalescence  approaches. 
The  height  and  duration  of  the  secondary  rise  in  temperature  will  depend 
upon  the  severity  of  the  infection  and  the  character  of  the  eruption.  Dur- 
ing the  stage  of  invasion  cutaneous  eruptions  may  occur  in  a  small  per- 
centage of  cases.  Both  erythematous  and  petechial  rashes  are  seen ;  the  lat- 
ter, which  occur  about  the  second  day,  when  associated  with  the  symptoms 
above  noted,  are  of  diagnostic  importance. 

The  ENANTHEM  is  oue  of  the  most  valuable  of  diagnostic  symptoms, 
as  it  commonly  occurs  from  twelve  to  twenty-four  hours  before  the  skin 
eruption.  It  consists  of  small  red  papules  which  can  be  distinctly  seen 
and  felt  on  the  hard  and  soft  palate,  and  may  occur  on  any  portion  of 
the  mucous  membrane  of  the  mouth.  These  papules  become  vesicles,  and, 
if  not  ruptured,  pustules;  the  rupture,  however,  usually  occurs  during 
the- vesicular  stage.  As  an  examining  physician  to  a  large  general  hos- 
pital many  years  ago,  I  had  the  opportunity  of  testing  the  value  of  the 
enanthem  in  making  an  early  diagnosis  of  these  cases.  During  the  epi- 
demic of  smallpox  then  prevailing  every  patient  applying  for  admission 
to  the  general  hospital  was  carefully  examined  for  the  smallpox  enanthem 
and  in  many  cases  the  diagnosis  was  made  upon  this  sign  and  the  patient 
sent  to  the  smallpox  hospital,  to  break  out  the  next  day  with  a  typical 
skin  eruption.  The  importance  of  making  the  diagnosis  at  this  early  period 
is  greater  because  the  time  of  great  contagiousness  begins  with  the  exan- 
them  stage.    Prior  to  this  the  disease  is  but  feebly  contagious. 

Stage  of  Eruption. — About  the  third  day  the  characteristic  skin- 
eruption  commences  to  make  its  appearance,  and  the  pain  in  the  back, 
headache,  gastric  disturbance  and  fever  quickly  subside.  The  eruption 
first  shows  itself  as  small  red  papules,  which  can  be  felt  as  well  as  seen; 


VARIOLA  347 

as  thcv  increase  in  size  they  give  to  the  skin  a  peculiar  shotty  feel.  On 
the  third  clay  the  papule  becomes  slowly  transformed  into  a  vesicle  filled 
with  slightly  grayish  fluid;  as  the  vesicle  increases  in  size  it  becomes  dis- 
tinctly umbilicated  and  is  surrounded  by  a  small  hyperemic  zone.  About 
the  eighth  or  the  ninth  day  the  vesicle  is  converted  into  a  pustule,  the 
contained  fluid  having  a  yellow  color.  During  this  time  as  the  pustule 
matures  the  surrounding  skin  becomes  more  indurated  and  inflamed,  so 
that  if  the  pustules  are  located  near  together,  the  whole  surface  becomes 
inflamed  and  indurated.  The  pustule  maintains  its  umbilicated  form  for 
a  number  of  days  and  then  slowly  begins  to  dry,  forming  a  brown  scab. 
This  change  commences  about  the  twelfth  day,  and  with  it  the  surround- 
ing skin  becomes  less  inflamed;  as  the  inflammation  subsides  the  crusts 
become  dryer  and  begin  to  drop  off  during  the  third  w^eek,  leaving  a  red 
scar.  General  desquamation  then  begins  and  is  usually  completed  about 
the  end  of  the  sixth  week;  in  milder  cases  earlier,  in  more  severe  cases 
later.  The  smallpox  eruption  first  makes  its  appearance  on  the  face,  then 
spreads  to  the  trunk  and  later  to  the  extremities.  It  is  especially  profuse 
around  the  neck  and  back,  and  not  so  marked  below  the  knees  and  on  the 
abdomen.  As  previously  noted,  there  is  a  secondary  rise  of  fever  during 
the  pustular  stage,  and  as  the  eruption  reaches  its  height,  about  the  ninth 
or  tenth  day,  the  skin  may  become  so  swollen  as  to  produce  great  pain. 
In  severe  forms  of  the  disease,  where  the  skin  is  very  intensely  inflamed, 
the  pain  is  very  acute;  the  location  of  individual  pocks,  as  for  example 
under  the  nail*  in  the  auditory  canal,  and  in  the  larynx,  and  in  the  eye, 
may  greatly  increase  the  suffering,  and  in  the  latter  location  may  result  in 
loss  of  sight. 

The  Urine. — Welsh  and  Schamberg  found  albuminuria  in  50  per 
cent,  of  cases  which  recovered,  and  in  841/0  per  cent,  of  the  fatal  cases. 
Acute  Bright's  disease,  however,  is  a  rather  rare  complication. 

Blood. — There  is,  as  a  rule,  a  marked  leukocytosis,  especially  during 
the  vesicular  stage.  The  lymphocytes  are  increased  and  the  polymor- 
phonuclears decreased.  The  red  blood  cells  are  greatly  diminished  in  the 
later  stages  of  this  disease. 

Clinical  Forms. — Variola  may  present  itself  in  many  forms.  The  mild 
cases  have  been  termed  varioloid.  These  commonly  occur  in  vaccinated 
individuals  in  whom  the  immunity  derived  from  the  vaccination  has  par- 
tially run  out.  In  these  cases  the  constitutional  symptoms  are  mild  and  the 
eruption  very  slight ;  only  a  few  pocks  may  occur.  From  this  mild  type  we 
have  every  grade  of  severity  to  the  confluent  form,  in  which  the  pustules  are 
so  close  together  that  they  become  confluent,  and  the  associated  dermatitis  is 
therefore  very  much  aggravated.  In  these  cases  the  constitutional  symptoms 
are  not  only  severe,  but  the  pustular  stage  of  the  disease  presents  a  very 
revolting  picture ;  the  patient's  face  and  eyes  being  so  swollen  that  he  can- 
not be  recognized  by  his  best  friend.  Hemorrhagic  smallpox  is  a  very  grave 
form,  in  which  the  pocks  become  hemorrhagic  and  hemorrhages  occur  from 
mucous  membranes.    The  constitutional  symptoms  are  profound  and  death 


348  VARIOLA,  VACCINIA,  AND  VARICELLA 

usually  results.  Purpuric  smallpox  is  a  fatal  form  in  which  petechial 
hemorrhages  appear  as  early  as  the  third  day,  taking  the  place  of  the  ordi- 
nary eruption.  Hemorrhages  occur  from  mucous  membranes  and  from 
the  kidney  and  the  patient  dies,  as  a  rule,  before  the  characteristic  erup- 
tion is  developed. 

Diagnosis. — Before  the  skin  eruption  appears,  the  diagnosis  of  small- 
pox may  be  made  by  the  constitutional  symptoms,  the  petechial  rash,  and 
the  typical  enanthem  on  the  palate.  After  the  skin  eruption  appears  the 
only  disease  with  which  smallpox  is  likely  to  be  confused  is  chickenpox, 
and  the  differential  diagnosis  of  these  two  conditions  is  given  in  the  chap- 
ter on  that  disease. 

Prophylaxis. — Vaccination  is  the  all-important  measure  in  the  prophy- 
laxis of  smallpox.  The  disease  may  be  prevented  in  this  way.  This  sub- 
ject is  discussed  under  Vaccination.  The  only  other  measure  of  any 
importance  is  the  absolute  and  complete  isolation  of  the  patient,  and  this 
can  only  be  done  satisfactorily  by  removing  the  patient  to  a  smallpox 
hospital.  If  he  is  treated  at  home  the  other  members  of  the  family  should 
leave  the  house,  and  he  should  be  given  into  the  hands  of  the  doctor  and 
trained  nurses.  Under  these  conditions  the  most  rigid  quarantine  pos- 
sible should  be  established,  even  more  rigid  than  that  described  under 
Scarlet  Fever. 

Treatment— During  the  stage  of  invasion  the  patient  is  to  be  made  as 
comfortable  as  possible  by  symptomatic  treatment.  For  the  fever,  frequent 
spongings  of  the  body  with  cool  water  should  be  resorted  to  if  it  adds  to 
the  comfort  of  the  patient.  An  ice-bag  to  the  head  will  modify  the  head- 
ache, the  nervous  symptoms,  and  help  to  reduce  the  temperature.  Bromid 
of  potash,  chloral  and,  if  necessary,  sulphate  of  codein  or  morphin,  in  doses 
suited  to  the  age  of  the  child,  may  be  used  to  relieve  the  intense  suffering 
of  this  stage.  Chloral  and  bromid  of  potash  are  especially  valuable  in 
young  children  for  the  control  of  the  convulsions  and  other  nervous  symp- 
toms, and  if  the  stomach  be  so  irritable  that  these  drugs  cannot  be  given  by 
the  mouth,  then  the  chloral  alone  should  be  given  by  the  rectum.  The 
diet  during  the  acute  stage  should  consist  of  milk,  cereals,  bread  and  fruit 
juices,  the  object  being  to  furnish  nutrition  without  overtaxing  the  diges- 
tive organs  or  the  kidneys. 

With  the  secondary  rise  in  temperature  which  occurs  during  the  pus- 
tular stage  of  the  eruption,  active  symptomatic  treatment  is  again  de- 
manded to  relieve  the  distress  produced  by  the  swelling  and  inflammation 
of  the  skin.  The  itching  during  this  stage  may  be  very  great  and  the  pa- 
tient must  be  prevented  from  scratching.  The  tearing  of  the  pocks  on  the 
face  should  be  especially  guarded  against  to  prevent  scarring.  Cold  ap- 
plications offer  the  greatest  relief;  these  may  be  made  by  wringing  cloths 
out  of  ice-cold  water  and  applying  them  as  a  mask  to  the  face  or  to  other 
portions  of  the  body  where  the  suffering  is  intense.  Carbolic  acid  may 
be  added  to  the  water,  as  this  helps  somewhat  to  relieve  the  itching.  In 
severe  cases  the  eye  demands  careful  attention,  and  as  the  conjunctivitis 


VACCINIA  349 

becomes  marked  it  is  necessary  to  separate  the  lids  and  wash  out  the  ac- 
cumulated discharges  with  a  weak  boric  acid  solution.  Cloths  wrung  out 
of  ice-water  should  be  applied  to  the  lids.  Pharyngitis  should  be  treated 
by  weak  alkaline  antiseptics.  In  rare  cases  the  eruption  extends  to  the 
larynx,  threatening  suffocation;  this  condition  may  demand  tracheotomy. 
As  smallpox  in  the  unvaccinated  is  a  very  dangerous  disease  and  one  in 
which  rather  sudden  collapse  is  not  uncommon,  active  stimulation  may  be 
demanded  at  any  time.  For  this  purpose  alcohol  in  the  form  of  whiskey 
or  brandy  should  be  freely  administered  in  combination  with  tincture  of 
strophanthus  or  tincture  of  digitalis.  The  red-light  treatment  of  small- 
pox is  believed  to  exercise  a  favorable  influence  on  the  skin  lesions.  This 
can  be  used  only  in  a  specially  prepared  room  where  all  the  light  is  fil- 
tered through  red  glass. 

VACCINIA 

Cowpox  is  believed  to  be  modified  smallpox,  as  it  occurs  in  the  cow; 
it  manifests  itself  in  a  vesiculo-pustular  eruption  on  the  udder  and  teats. 
Vaccination  with  the  virus  of  the  cowpox  vesicle  communicates  this  disease 
to  man,  producing  vaccinia  and  protecting  him  from  the  contagion  of 
smallpox  for  a  variable  length  of  time. 

History. — Before  the  time  of  Jenner  it  was  known  to  dairy  workers 
that  an  attack  of  cowpox  conferred  immunity  from  smallpox.  In  fact 
Jenner's  attention  was  called  to  this  subject  by  coming  in  contact  with 
dairy  people.  After  a  careful  investigation  he  made  his  first  vaccination 
on  May  14,  1796.  This  was  done  with  virus  taken  from  a  milkmaid  suf- 
fering from  cowpox;  the  subject  was  a  boy  named  James  Phipps;  subse- 
quently with  the  same  virus  he  vaccinated  his  own  son,  and  a  number  of 
other  children.  Later  he  inoculated  some  of  these  children  with  the  virus 
of  smallpox  and  otherwise  exposed  them  to  the  contagion  of  this  disease, 
but  none  of  them  contracted  it.  Jenner  continued  his  investigations  over 
a  period  of  two  years,  and  in  1798  published  his  observations  in  which  he 
stated  that  i^atients  who  had  had  cowpox  were  ever  after  protected  from 
smallpox,  and  that  smallpox  could  therefore  be  prevented  by  inoculating 
the  patient  with  cowpox.  Thus  originated  perhaps  the  greatest  of  all  med- 
ical discoveries,  vaccination;  a  discovery  which  has  saved  more  lives  than 
any  other,  and  which  has  almost  obliterated  smallpox,  the  most  terrible 
pest  of  the  seventeenth  and  eighteenth  centuries. 

It  is  difficult  for  us  at  the  present  time  to  realize  that  the  discovery 
of  vaccination  by  Edward  Jenner  was  and  still  remains  the  greatest  of 
all  triumphs  of  preventive  medicine.  Crandall,  who  has  most  carefully 
studied  the  vast  literature  of  this  subject,  says:  "A  hundred  years  ago 
smallpox  was  justly  regarded  as  the  Attila  of  diseases,  the  very  scourge 
of  God,  overrunning  countries  and  destroying  populations.  When  Jenner 
performed  his  first  vaccination  it  was  causing  one-tenth  of  all  the  deaths 
of  the  human  race.     Bemouilli,  the  mathematician,  estimated  that  more 


350  VARIOLA,  YACCTXIA.   AXD  VARICELLA 

than  60.000.000  of  the  inhahitants  of  Europe  died  of  smallpox  during  the 
eighteenth  century.  Others  })lace  the  number  even  higher.  Specific  proof 
of  its  fatality  is  shown  by  Cowan's  vital  statistics  of  Glasgow.  In  that 
city  between  1783  and  1792,  36  per  cent,  of  all  deaths  under  ten  years 
of  age  were  due  to  smallpox.  One-third  of  all  the  deaths  in  Europe  under 
ten  years  were  due  to  the  same  cause.  When  smallpox  was  introduced  into 
Mexico  by  the  Spaniards  in  1520,  3.500,000  died  within  a  few  years.  In 
1737  in  Iceland,  18,000  in  a  population  of  50,000  died  in  a  single  year. 
It  is  believed  that  6,000.000  North  American  Indians  fell  victims  of  its 
ravages."  In  contrast  with  this  let  me  quote  the  opening  sentence  of  a 
recent  encyclopedic  article  on  smallpox  by  Ch.  Biiumler,  of  Freiberg: 
"There  has  been  no  opportunity  of  observing  variola  in  any  form  in  this 
clinic  for  nine  years;  still  it  is  necessary  for  every  well-informed  physician 
to  have  a  knowledge  of  this  important  disease.  As  a  result  of  strict  vac- 
cination and  revaccination  in  Germany,  the  disease  has  been  prevented 
from  appearing,  so  that  many  physicians  have  never  had  an  opportunity 
of  seeing  smallpox."  The  results  which  have  been  attained  by  Germany 
could  be  obtained  in  other  countries  if  compulsory  vaccination  were 
adopted.  In  the  United  States  smallpox  is  kept  alive  by  the  fact  that 
there  still  exists  an  ignorant  negro  and  uneducated  foreign  population  and 
a  few  fanatics  who  "do  not  believe  in  vaccination." 

The  Vaccine  Virus. — In  the  early  experiments  vaccinations  were  made 
with  the  lymph  taken  directly  from  the  cowpox  vesicle.  Later  humanized 
virus  came  into  very  general  use,  the  subject  being  vaccinated  either 
with  the  fresh  lymph  from  a  human  vaccine  vesicle  or  with  the  dried 
lymph  in  the  form  of  scabs  or  crusts  which  came  from  the  matured  vac- 
cine vesicle.  As  time  went  on  public  opinion  was  much  opposed  to  the 
use  of  humanized  vims,  because  of  the  exaggerated  views  then  prevalent 
of  the  danger  of  transmitting  syphilis,  tuberculosis  and  possibly  other 
diseases.  At  the  present  time  humanized  virus  is  rarely  used,  bovine 
virus  having  taken  its  place.  This  vaccine  virus  is  now  prepared  from 
the  serum  of  the  cowpox  vesicle,  and  is  put  on  the  market  in  the  form  of 
a  glycerinated  bovine  virus  in  hermetically  sealed  tubes,  or  on  ivory  points 
which  are  themselves  protected  from  contamination  by  being  put  up  in 
glass  tubes  or  other  coverings;  the  object  being  to  present  to  the  public 
a  pure,  sterile  bovine  virus  which  can  be  used  without  fear  of  infecting 
the  patient  with  pathogenic  organisms. 

Technique  of  Vaccination. — Vaccination  is  to  be  performed  under 
strictly  aseptic  conditions.  The  skin  is  to  be  carefully  cleansed  with  soap 
and  water  and  then  with  alcohol.  The  operation  may  be  made  with  an  ordi- 
nary sewing  needle,  or  with  the  sterile  ivory  vaccine  points  above  described. 
If  the  needle  is  used  it  should  be  sterilized  by  heating,  and  with  its  point 
the  skin  is  to  be  carefully  scratched  four  or  five  times,  both  in  a  longi- 
tudinal and  transverse  diameter,  producing  a  raw  surface  about  one-sixth 
of  an  inch  square.  The  scarification  should  be  deep  enough  to  remove 
the  superficial  epithelium,  leaving  a  red.  raw,  but  not  bleeding,  surface. 


VACCINIA  351 

Into  this  raw  siirface  the  vaccine  virus  is  rubbed  with  the  ivory  vaccine 
point,  or  some  other  sterile  instrument.  The  wound  should  then  be  allowed 
to  dry  before  the  clothing  comes  in  contact  with  it;  this  commonly  re- 
quires fifteen  or  twenty  minutes.  Following  this  operation  the  vaccine 
wound  is  to  be  carefully  protected  from  traumatic  injury  and  infection. 
The  point  on  the  skin  usually  selected  for  vaccination  is  the  upper  and 
outer  surface  of  the  left  arm  at  or  near  the  insertion  of  the  deltoid.  An- 
other point  of  selection  is  the  outer  surface  of  the  left  leg,  six  or  eight 
inches  above  or  below  the  knee.  Of  these  two  locations  the  arm  is  by 
far  the  best.  The  leg,  however,  may  be  selected  in  young  infants  under 
one  year  of  age,  since  at  this  time  of  life  it  is  almost  as  easy  to  properly 
care  for  the  vaccine  wound  on  the  leg  as  it  is  upon  the  arm.  In  children 
old  enough  to  be  upon  their  feet  there  is  more  or  less  danger  that  the 
vaccination  wound  on  the  leg  may  be  injured  and  contaminated;  for  this 
reason  first  vaccinations  in  older  children  should  always  be  made  on  the 
arm.  If  not,  the  parents  should  be  made  to  assume  the  responsibility  of 
keeping  the  child  off  its  feet  during  the  period  of  marked  inflammation 
in  and  "around  the  vaccine  vesicle.  For  esthetic  reasons  the  physician  is 
very  frequently  requested  to  vaccinate  girls  upon  the  leg,  as  the  scar  upon 
the  arm  is  unsightly.  Vaccination  should,  if  possible,  be  performed  during 
the  first  year  of  life,  but  it  is  advisable  to  wait  until  after  the  child  is 
three  months  of  age,  or  until  its  nutritional  problems  are  solved;  it  is 
then  ready  for  vaccination,  and  the  earlier  the  operation  is  made  the 
milder  will  be  the  course  of  the  vaccinia  and  the  less  trouble  will  there 
be  in  the  care  of  the  wound.  If,  however,  the  infant  be  tuberculous  or 
come  from  a  tuberculous  family,  or  if  it  be  malnourished  from  lack  of 
proper  food  or  other  causes,  vaccination  may  be  postponed  until  these 
nutritional  faults  are  corrected.  In  the  meantime,  however,  should  small- 
pox appear  in  the  community,  the  child  should  be  vaccinated  without  fur- 
ther delay. 

Incubation  Period. — The  incubation  period  of  vaccinia  is  from  three 
to  five  days,  that  of  smallpox  eight  to  twenty  days;  the  average  incuba- 
tion period  of  vaccinia  is  four  days,  that  of  smallpox  twelve  days.  These 
are  most  important  facts,  since  they  explain  why  a  patient  who  has  been 
exposed  to  smallpox  may  even  then  be  protected  by  prompt  vaccination. 
If  the  vaccination  be  made  within  the  first  day  or  two  after  exposure  to 
the  smallpox  contagion,  the  patient  may  escape  smallpox,  as  the  vaccinia 
reaches  its  height  before  smallpox  has  had  time  to  develop.  If  the  vac- 
cination be  made  four  or  five  days  after  exposure  to  the  smallpox  con- 
tagion, the  vaccinia  may  still  precede  the  smallpox  in  its  development  and 
cause  it  to  run  a  very  mild  course. 

Clinical  Manifestations. — Directly  following  vaccination  the  wound 
heals  and  on  the  fourth  or  fifth  day  thereafter  a  faint  red  spot  makes  its 
appearance,  which  soon  manifests  itself  as  a  papule  with  a  red  base.  On 
the  sixth  or  seventh  day  this  papule  becomes  a  vesicle  of  grayish  color  with 
a  slight  zone  of  redness  and  contains  a  clear  sterile  lymph.  On  the  eighth 
24 


352  VARIOLA,  VACCINIA,  AND  VARICELLA 

day  the  vesicle  becomes  contaminated  with  bacteria  and  the  lymph  be- 
comes clouded  with  jnis  corpuscles,  so  that  by  the  tenth  day  a  pustule  has 
taken  the  place  of  the  vesicle.  In  the  meantime  as  the  pock  develops  from 
the  vesicle  into  the  pustule  it  becomes  umbi Heated,  a  slight  central  de- 
pression showing  on  the  eighth  or  ninth  day.  During  this  time  the  zone 
of  redness  which  surrounded  the  vesicle  is  much  increased  in  size  and  en- 
circles the  pustule  from  half  an  inch  to  an  inch  or  more  in  every  direc- 
tion; this  zone  is  more  or  less  thickened  and  indurated  and,  near  the  pus- 
tule, slightly  tender  to  the  touch.  From  the  ninth  to  the  eleventh  day  the 
disease  is  at  its  height,  and  during  this  period  adjacent  lymph  nodes  are 
swollen  and  tender.  When  the  arm  is  the  site  of  the  vaccination  the 
axillary  lymph  nodes  are  especially  involved,  and  may  appear  as  hard, 
tender  tumors  the  size  of  a  hickory  nut.  After  the  eleventh  day  the  in- 
flammatory process  subsides,  the  umbilicated  pustule  begins  to  dry  up 
and  form  a  scab.  The  axillary  lymph  nodes  diminish  in  size,  the  sur- 
rounding zone  of  redness  and  induration  gradually  diminishes,  and  all 
the  acute  symptoms  disappear.  The  scab  or  crust  does  not  usually  fall 
off  until  the  end  of  the  third  week,  and  may  remain  a  week  longer.  Dur- 
ing this  period  great  care  should  be  exercised  to  have  it  remain  as  long 
as  possible,  to  be  finally  cast  off  by  necrotic  processes  which  have  under- 
mined it.  With  the  falling  off  of  the  scab  a  depressed,  red  surface  is  left, 
which  later  marks  the  site  of  the  permanent  scar,  which  usually  has  a 
pitted  appearance. 

With  the  onset  of  other  acute  symptoms  fever  usually  appears  on  the 
eighth  or  ninth  day.  In  infants  under  one  year  of  age  the  fever  is  very 
slight,  and  even  in  older  children  it  does  not  commonly  rise  above  103° 
or  103°F. ;  it  may,  however,  reach  104:°F.  Soon  thereafter  the  tempera- 
ture begins  to  fall  and  may  reach  normal  within  two  or  three  days.  The 
febrile  reaction  in  vaccinia  varies  greatly.  It  may  be  very  slight  and 
evanescent,  and  it  may  be  well  marked  and  last  for  four  or  five  days 
without  indicating  septic  contamination  of  the  wound  or  other  complica- 
tions. The  typical  lesion  or  pock  of  vaccinia  in  first  vaccinations  runs 
the  same  course  as  the  lesion  of  smallpox.  It  is  first  a  papule,  then  a 
vesicle,  pustule,  scab  and  scar.  These  stages,  however,  are  milder  and 
shorter  in  vaccinia  than  they  are  in  smallpox,  but  they  are  characteristic 
of  vaccinia,  and  a  vaccine  sore  that  does  not  present  this  sequence  is  ab- 
normal, and  may  not  afford  protection  against  smallpox.  The  severity  of 
the  course  of  vaccinia  does  not  increase  its  power  of  protection.  The  mild 
course  which  this  disease  runs  in  infancy  confers  immunity  for  as  long 
a  period  as  the  more  severe  vaccinia  of  the  older  child.  On  the  other  hand, 
it  should  also  be  noted  that  vaccinia  marked  by  severe  local  and  constitu- 
tional symptoms  is  not  to  be  considered  abnormal,  provided  the  disease 
runs  the  typical  course  above  outlined.  It  simply  means  that  some  in- 
dividuals are  more  susceptible  to  vaccinia,  as  they  are  to  other  contagious 
diseases. 

Secondary  Rashes. — In  some  instances  a  dark  red  swelling  occurs  at 


VACCINIA  353 

the  point  of  vaccination  instead  of  the  typical  sore.  This  has  been  de- 
scribed as  the  "raspberry  excrescence."  It  is  firm,  considerably  elevated 
above  the  surface  of  the  skin,  but  is  not  inflamed  or  tender,  and  has  no 
discharge.  This  condition  is  brought  about  by  some  abnormality  in  the 
virus  used  and  offers  no  protection  against  smallpox.  It  commonly  per- 
sists for  weeks  and  may  last  for  months  before  it  finally  disappears.  As- 
sociated with  normal  vaccination,  we  occasionally  have  a  general  vaccinia 
eruption,  in  which  the  pustules  may  be  scattered  in  large  numbers  over 
the  surface  of  the  body,  resembling  chickenpox.  These  pocks  run  through 
the  typical  stages  of  the  local  sore  produced  by  vaccination,  but  they  are 
much  smaller  and  run  their  course  in  a  shorter  time.  Erythematous  rashes 
resembling  German  measles,  mottled  rose-colored  patches  resembling  true 
measles,  and  urticaria  may  also  occur. 

Secondary  Vaccinations. — Secondary  vaccinations  may  rarely  occur 
from  the  accidental  transfer  of  the  vaccine  virus  from  the  local  sore  to 
some  other  part  of  the  body ;  this  transfer  usually  comes  through  the  hand 
of  the  patient.  The  genital  organs  are  the  most  common  site  of  secon- 
dary vaccinations.  The  eye  may  also  be  inoculated.  Accidental  vaccinia 
may  also  occur  in  unvaccinated  children  suffering  from  eczema.  In  these 
cases  generalized  vaccinia  may  develop  and  the  disease  may  terminate 
fatally. 

Complications.  — The  most  common  complication  is  a  septic  infection 
of  the  local  sore  by  pyogenic  microorganisms.  As  a  result  more  or  less 
serious  cellulitis  may  occur,  involving  the  tissues  of  the  arm  around  the 
point  of  vaccination;  even  a  general  septicopyemia  may  result.  Abscesses 
in  the  lymphatic  glands  of  the  axilla  and  neck  may  occur,  especially  in 
tuberculous  children.  Impetigo  and  erysipelas  are  rare  complications. 
Syphilis  and  tuberculosis  are  perhaps  never  transmitted  by  vaccination. 
The  latter  disease,  however,  may  be  aggravated  by  vaccinia.  Tetanus  has 
been  conveyed  by  vaccination ;  this,  however,  is  a  very  rare  occurrence,  and 
could  only  happen  where  the  animal  producing  the  virus  was  suffering 
from  tetanus. 

Revaccination.  — A  successful  vaccination  fully  protects  the  individual 
from  vaccinia  and  from  smallpox  for  a  more  or  less  indefinite  period  of 
time.  In  some  instances  the  immunity  thus  produced  lasts  throughout 
a  long  life-time;  as  a  rule,  however,  it  begins  to  run  out  after  five  or  six 
years,  and  from  that  time  on  the  child  becomes  more  and  more  suscep- 
tible to  smallpox.  During  this  period  of  partial  immunity  the  individual 
may  have  smallpox  in  a  mild  form  (varioloid).  It  is  therefore  advisable 
to  follow  the  first  vaccination  by  a  second  vaccination  six  or  seven  years 
later,  and  thereafter  the  individual  should  be  vaccinated  during  every 
smallpox  epidemic,  if  there  has  not  been  a  successful  vaccination  within  the 
last  five  years.  Second  vaccinations  commonly  run  a  mild  course,  and  the 
local  sore  produced  thereby  gives  little  annoyance  and  is  associated  with 
no  constitutional  symptoms.  An  infected  vaccination  wound  or  other  in- 
juries may  present  a  scar  resembling  that  produced  by  a  successful  vac- 


354  VARIOLA,  VACCINIA,  AND  VARICELLA 

cination.     11ie  so-called  typical  scar  should  not.  therefore,  exempt  individ- 
uals from  vaccination  during  smallpox  epidemics. 

Treatment. — In  the  care  of  the  local  sore  two  things  are  sought,  first, 
to  prevent  traumatic  injury,  and,  second,  to  prevent  infection.  Immediate- 
ly following  the  operation  of  vaccination  the  wound  should  be  covered 
with  clean  cotton  or  linen  cloth.  This  should  not  be  bandaged  about  the 
arm,  as  such  a  dressing  drags  the  sore  in  the  putting  on  and  off  of  cloth- 
ing. A  strip  of  clean  cloth  covering  the  sore  may  be  held  by  adhesive 
plaster  placed  far  enough  away  to  not  come  within  the  zone  of  conges- 
tion produced  by  the  sore.  A  cloth  of  this  kind  may  be  renewed  every  day 
and  the  vaccine  wound  dusted  with  boracic  acid  powder.  If  there  is  much 
itching  carbolized  vaselin  may  be  used  not  on  but  around  the  wound. 
Oils,  ointments  and  moist  dressings  to  the  sore  are  contraindicated  as 
long  as  it  remains  dry  and  uninfected.  The  cloth  for  the  protection  of  the 
wound  may  also  be  stitched  to  the  undershirt,  extending  several  inches 
above  and  below  the  point  of  vaccination,  and  this  should  be  changed  every 
day.  This  precaution  is  even  better  than  changing  the  child's  undercloth- 
ing, since  a  soft  cotton  or  linen  rag  is  less  irritating  to  the  vaccine  wound 
than  the  material  ordinarily  used  for  underclothing.  If  the  sore  becomes 
moist  and  adheres  to  the  rag,  dusting  powders  are  of  service ;  among  these 
aristol  and  chemically  pure  boracic  acid  are  valuable.  They  should  be 
applied  frequently  during  the  day  and  the  sore  protected  by  a  light  vac- 
cination shield,  large  enough  not  to  injure  it  and  so  constructed,  of  wire 
or  other  material,  that  there  will  be  a  free  access  of  air  to  the  wound.  If 
infection  results  in  a  cellulitis  the  patient  should  be  confined  to  bed,  all 
bandages  removed  and  moist  dressings  of  1  to  1,000  bichlorid  of  mer- 
cury or  5  per  cent,  aluminium  acetate,  used.  Vaccination  shields  are  of 
special  value  in  protecting  the  scab  after  the  local  inflammation  has  sub- 
sided. 

VARICELLA 

Varicella,  or  chickenpox,  is  an  acute  infectious  disease  characterized  by 
a  vesicular  eruption  which  is  commonly  preceded  by  fever  and  other  slight 
constitutional  symptoms,  fin  its  early  history  it  was  confounded  with  mild 
forms  of  smallpox,  with  which  it  is  now  known  to  have  no  connection. 

Etiology. — Although  the  specific  microorganism  of  this  disease  has  not 
been  discovered,  it  is  known  to  be  very  contagious;  only  slightly  second- 
ary to  measles  in  this  regard.  It  occurs  in  mild  epidemics,  spreading 
rapidly  through  schools,  families  and  institutions.  The  facility  with  which 
it  spreads  among  the  susceptible  members  of  confined  communities  shows 
that  its  contagious  principle  is  readily  carried  by  fomites  through  the  air 
to  all  parts  of  the  room,  and  that  personal  contact  of  the  sick  with  the 
well  is  almost  always  followed  by  transmission  of  the  contagion.  That 
the  disease  is  not  readily  conveyed  from  house  to  house  and  from  institu- 
tion to  institution  is  evidence  that  the  contagion  is  short-lived  and  is  per- 


VARICELLA 


355 


haps  very  rarely  carried  l\v  a  tliird  party  or  1)y  the  clothing  and  other  l)e- 
longings  of  the  patient.  There  is  also  little  doiiht  but  that  the  period  of 
great  contagiousness  lasts  but  a  short  time,  probably  only  during  the  four 
or  five  days  covered  by  the  acute  symptoms;  after  that  there  is  little  dan- 
ger of  transmitting  the  contagion ;  otherwise  the  disease  would  be  widely 
spread  by  convalescent  patients,  still  carrying  the  scales  and  scabs  of  the 
eruption.  Varicella  is  preeminently  a  disease  of  childhood.  Perhaps  90 
per  cent,  of  the  cases  occur  in  children  under  ten  years  of  age.  In  adults 
and  nurslings  it  is  rare. 

Incubation. — By  most  writers  this  period  is  placed  at  about  fourteen 
days;  it  may,  however,  be  a  few  days  longer  or  shorter,  and  Gregory 
states  that  it  is  less  than  one  week. 

Symptomatology. — The  onset  is  marked  by  a  rise  in  temperature,  asso- 
ciated with  headache,  nausea, 
and  sometimes  with  chilly 
sensations.  The  fever  preced- 
ing the  eruption  is  slight,  but 
later  it  may  rise  to  103°  F. 
and  in  severe  cases  even  to 
105°  F.  It  lasts  from  two  to 
six  days,  and  is  rather  mark- 
edly rem^tent.  The  head- 
ache, nausea  and  general  dis- 
comfort disappear  within 
thirty-six  hours  and  there- 
after the  patient  is  comforta- 
ble. 

The  EXANTHEM  is  the 
characteristic  symptom  upon 
which  the  diagnosis  is  made; 
it  appears  early  and  develops 
rapidly.  In  mild  cases  the 
constitutional  symptoms  may 
be  so  slight  as  to  be  over- 
looked, and  attention  is  first 
called  to  the  child's  illness  by 
the  eruption.  This  makes  its 
appearance  first  in  widely 
scattered  patches  on  the  face 
and  back,  quickly  spreading 
over  the  body  and  later  in- 
volving the  arms  and  legs. 
When  the  eruption  is  fully  developed  it  is  much  more  marked  .over  the  body 
than  on  the  face;  in  well-marked  cases  the  body  may  be  almost  covered  while 
the  face  shows  comparatively  few  vesicles.  The  eruption  first  appears  as 
violet-pink  macules,  which  later  become  small  vesicles  varying  greatly  in 


Fig.  58.- 


Varicella    Eruption    on    the    Fourth 
Day.     (Hecker  and  Trumpp.) 


356  VARIOLA,  VACCINIA,  AND  VARICELLA 

size,  froiu  1  to  10  mm.,  the  average  size  being  about  3  or  4  mm.  These 
vesicles  are  filled  with  a  clear  fluid  which  later  becomes  cloudy;  they  are 
surrounded  by  a  small  erythematous  zone.  Within  twenty-four  or  forty- 
eight  hours  they  begin  to  dry  up,  and  during  this  period  of  desiccation  may 
appear  slightly  umbilicated ;  this  umbilication  is  due  to  the  drying  process 
preceding  scab  formation.  The  small  dark  scab,  which  marks  the  site  of 
the  vesicle,  may  remain  for  two  or  three  weeks  before  it  finally  falls  off. 
The  chickenpox  eruption  is  characterized  not  only  by  the  great  variation 
in  the  size  of  the  vesicles,  but  more  especially  by  the  fact  that  they  appear 
in  successive  crops  on  the  same  parts  of  the  body,  so  that  where  the 
eruption  is  most  profuse  the  hand  may  cover  chickenpox  vesicles  in 
every  stage  of  development,  including  the  tiny  red  macule,  the 
matured  vesicle  and  the  desiccated  scab.  The  skin  eruption  during  its 
height  is  usually  associated  with  itching;  this  symptom  may  continue 
for  days. 

The  enanthem  may  be  of  value  in  the  differential  diagnosis.  It  appears 
in  the  form  of  vesicles  or  more  frequently  as  an  erosion  of  the  mucous 
membrane  locating  the  site  of  a  ruptured  vesicle,  and  is  surrounded  by  a 
pinkish-red  zone.  Following  the  breaking  of  the  vesicle  the  erosion  is 
frequently  covered  by  a  thin  white  exudate.  This  eruption  occurs  most 
commonly  on  the  soft  and  hard  palate,  but  may  also  appear  on  the  pillars 
of  the  pharynx,  tonsils  and  rarely  on  the  gums  and  tongue.  The  enanthem 
is  coincident  in  appearance  with  the  exanthem.  Painful  and  distressing 
local  symptoms  may  be  produced  by  pocks  in  unusual  places;  in  the  ear 
they  may  produce  earache,  in  the  throat  an  irritating  and  harassing  cough, 
at  the  mouth  of  the  meattis  urinarius  painful  urination,  and  in  the  vulva 
an  uncomfortable  swelling. 

Blood. — There  is  a  moderate  leukocytosis  during  the  pustular  stage 
with  an  increase  of  polymorphonuclears;  no  eosinophiles. 

Complications.  — While  the  course  of  chickenpox  in  the  vast  majority 
of  cases  is  very  benign  and  the  prognosis  in  uncomplicated  cases  is  in- 
variably good,  it  should  be  remembered  that  it  may  be  followed  by  serious 
complications.  Tuberculosis  is  the  most  common.  Bright's  disease,  gan- 
grenous dermatitis,  adenitis  and  arthritis  may  rarely  occur. 

Diagnosis. — The  only  disease  with  which  chickenpox  may  be  confused 
is  varioloid.  From  this  it  may  be  differentiated  by  the  fact  that  in 
chickenpox  every  stage  of  the  eruption  may  be  found  on  the  same  part  of 
the  body  at  the  same  time,  while  in  smallpox  the  skin  lesions  on  any  part 
of  the  body  are  in  the  same  stage  of  development.  In  chickenpox  also 
there  is  greater  variation  in  the  size  of  the  vesicles  and  they  do  not  have 
the  early  shotty  feel  of  the  smallpox  vesicle.  As  emphasized  by  Council- 
man the  "vesicular  fluid  of  the  chickenpox  vesicle  is  contained  in  a  single 
cell  and  not  in  a  system  of  cells  as  in  smallpox,  so  that  a  single  pin  prick 
at  once  flattens  the  chickenpox  vesicle.  The  vesicle  in  chickenpox  is  never, 
as  in  smallpox,  umbilicated,  although  it  may  appear  slightly  so  during  the 
stage  of  desiccation.    The  chickenpox  vesicle  runs  its  course  in  three  days. 


ETIOLOGY  357 

the  smallpox  vesicle  requiring  a  much  longer  time.  The  two  diseases  may 
also  be  differentiated  by  their  characteristic  enanthems. 

Immunity. — One  attack,  as  a  rule,  confers  lasting  immunity,  second 
attacks  are  extremely  rare. 

Prophylaxis. — Patients  suffering  from  this  disease  should  be  isolated. 
Tuberculous  children  should  be  especially  guarded,  as  chickenpox  may 
aggravate  an  existing  tuberculosis.  Because  of  the  mildness  of  this  in- 
fection it  is  practically  impossible  to  continue  the  quarantine  longer  than 
one  week.     This,  however,  covers  the  period  of  greatest  contagiousness. 

Treatment. — Chickenpox  is  a  mild,  self -limited  disease,  which  in  the 
great  majority  of  instances  requires  little  or  no  treatment.  A  prelim- 
inary laxative  should  be  given  and  during  the  acute  febrile  stage  the  pa- 
tient should  be  confined  to  bed.  The  diet  should  be  simple  and  composed 
largely  of  milk,  cereals,  purees  of  vegetables,  bread  and  fruit  Juices.  Al- 
buminous foods  should  be  avoided  or  partaken  of  sparingly,  the  object 
being,  as  in  the  other  acute  infections,  not  to  overtax  the  kidneys.  Phen- 
acetin  and  antipyrin  may  be  given  to  relieve  the  headache,  reduce  the 
fever,  and  make  the  patient  more  comfortable  during  the  acute  febrile 
stage,  but  these  drugs  should  be  used  only  when  they  are  needed  and  not 
as  a  routine  measure.  Lanolin  and  carbolized  vaselin  may  be  applied  to 
the  skin  to  relieve  the  itching.  Care  should  be  taken  to  prevent  the  pa- 
tient from  scratching  the  pocks,  as  this  may  result  in  infection  and  in  the 
production  of  unsightly  scars. 


CHAPTER  XLII 

MUMPS 
(Epidemic  Parotitis) 

Mumps  is  an  acute  infectious  disease  characterized  by  fever  and  by 
inflammation  of  the  salivary  glands,  especially  the  parotids. 

Etiology. — The  specific  microorganism  is  unknown.  The  investiga- 
tions, however,  of  Leveran  and  Catrin  are  of  importance  since  they  found 
in  the  blood,  in  the  parotid  gland,  in  the  testicle  and  in  the  edematous 
fluid  diplococci  which  arranged  themselves  in  twos  and  fours.  Diplococci 
have  also  been  found  in  Steno's  duct  and  in  abscesses  of  the  parotid,  com- 
plicating mumps.  Further  investigations,  however,  are  required  to  show 
whether  this  organism  is  etiologically  related  to  mumps.  The  specific 
cause  is  spread  by  the  well  coming  in  close  contact  with  the  sick.  The 
poison  cannot  be  carried  any  distance  through  the  air,  and  is  rarely  trans- 
ferred by  a  third  person.  Such  close  contact  is  required  for  the  spread 
of  this  contagion  that  there  is  little  difficulty  in  confining  it  by  quaran- 
tine regulations.  I  have  on  many  occasions  quarantined  cases  of  mumps 
in  the  end  room  of  a  children's  ward  without  having  the  infection  spread. 


358  MUMPS 

In  hospitals  and  in  other  institutions  where  a  large  nuniher  of  children 
occupy  the  same  room  tlie  disease  spreads  to  children  in  neighboring  beds 
rather  than  to  children  across  the  ward.  The  disease  occurs  in  epidem- 
ics, little  influenced  by  weather  conditions,  but  they  are  slightly  more 
common  in  winter  than  in  summer.  The  severity  of  the  disease  and  the 
degree  of  its  infectiousness  vary  greatly  in  different  epidemics.  Instances 
are  on  record  where  one-half  of  the  exposed  children  have  contracted  this 
disease.  In  milder  epidemics  not  more  than  20  per  cent,  of  those  exposed 
contract  it. 

Age. — Comby  reports  a  congenital  case.  The  disease  is  almost  un- 
known under  one  year  and  is  very  rare  under  two  and  over  forty;  sus- 
ceptibility increases  up  to  the  sixth  year.  The  great  majority  of  the  cases 
occur  between  the  sixth  and  fourteenth  year  of  life.  After  this  susceptibil- 
ity gradually  diminishes,  young  adults  about  twenty  years  of  age  still 
being  quite  susceptible,  but  in  old  age  the  disease  is  almost  unknown. 

Period  of  Contagion. — This  lasts  for  three  weeks  dating  from  the  be- 
ginning of  the  attack.  The  disease,  however,  may  be  contagious  for  a  few 
days  before  the  acute  symptoms  have  developed,  and  in  some  instances  it 
appears  that  the  contagion  may  last  for  five  or  six  weeks.  It  may  be  as- 
sumed that  the  period  of  greatest  contagion  is  during  the  first  week  while 
the  acute  symptoms  are  present,  and  that  it  gradually  diminishes  during 
the  next  two  weeks. 

Incubation. — Eighteen  days  is  the  average  period  of  incubation,  but 
it  may  vary  from  two  to  four  weeks. 

Immunity. — One  attack  commonly  confers  immunity.  Second  attacks 
are  unusual  and  third  attacks  rare. 

Symptomatology. — The  child  is  fretful,  languid,  sleepless,  loses  its  ap- 
petite, has  a  slight  elevation  of  temperature  with  headache,  backache,  and 
a  certain  amount  of  stiffness  and  tenderness  at  the  angle  of  the  jaw. 
Shortly  after  the  onset  of  these  symptoms,  usually  in  from  one  to  three 
days,  the  swelling  of  the  parotid  gland  appears,  and  there  is  localized  ten- 
derness and  an  increasing  stiffness  in  the  movement  of  the  jaw.  The 
swelling  appears  between  the  angle  of  the  lower  jaw  and  the  mastoid 
process.  It  gradually  obliterates  the  intervening  depression,  rises  and 
extends  in  front  of  the  car,  involving  the  whole  gland.  The  subcutaneous 
tissue  surrounding  the  parotid  not  infrequently  becomes  infiltrated  and 
edematous.  This  tumor  mass,  which  is  the  characteristic  sign  of  -the 
disease,  is  tense  and  firm,  does  not  pit  on  pressure,  is  located  in  front  of 
the  ear  and  extends  downward,  tilting  the  ear  backward  and  extending  into 
the  neck.  In  some  instances  only  one  parotid  is  affected,  but,  as  a  rule,  the 
other  begins  to  swell  three  or  four  days  later,  so  that  in  most  instances 
the  disease  is  bilateral,  giving  a  peculiar  squirrel-like  appearance  to  the 
face;  the  neck,  just  under  the  ears,  is  wider  than  the  face  itself. 

The  sub-maxillary  and  sub-lingual  glands  may  also  be  involved,  pro- 
ducing firm,  resistant,  tender,  swollen  masses.  These  glands  may  be  af- 
fected after  or  before  the  parotids,  or  the  disease  may  be  wholly  confined 


DIAGNOSIS  359 

to  the  sub-niaxillary  and  siib-lingiial  glands.  The  swelling  in  the  parotid 
gland  gradually  reaches  its  height  in  four  or  five  days,  remains  about  the 
same  for  two  days  and  then  rather  quickly  subsides,  lasting  in  all  from 
one  week  to  ten  days;  in  the  bilateral  cases  this  period  may  be  slightly 
prolonged  if  one  parotid  is  infected  some  days  after  the  other. 

There  is  more  or  less  pain  and  tenderness  associated  with  the  parotid 
swelling  which  may  be  aggravated  by  the  taking  of  acids  or  spicy  foods 
which  may  irritate  the  buccal  mucous  membranes.  The  pain  is  increased 
on  opening  the  Jaw.  This  causes  the  patient  to  keep  his  mouth  partly 
closed  in  speaking  and  in  taking  food,  and  in  unilateral  cases  to  tilt  the 
head  slightly  to  the  diseased  side  so  as  to  relax  the  tension  of  the  muscles. 
Sore  throat  is  commonly  complained  of  on  swallowing  and  an  examination 
of  the  mouth  shows  a  swelling  and  congestion  of  the  buccal  mucous  mem- 
brane around  Steno's  duct.  The  tonsils,  soft  palate  and  fauces  are  red 
and  congested. 

The  fever,  which  is  one  of  the  earliest  symptoms,  rises  by  the  second 
day  to  about  103°r.  In  severe  cases  it  may  reach  104°r.  This  continues 
for  four  or  five  days  and  falls  to  normal  soon  after  the  parotid  swelling 
reaches  its  height.  The  fall  in  temperature  may  be  postponed  or  inter- 
rupted by  the  involvement  of  other  glands  or  by  relapses  which  may  occur 
during  the  period  of  apparent  convalescence. 

Epistaxis  may  be  a  feature  of  the  disease  in  certain  epidemics.  Slight 
enlargement  of  the  spleen  and  external  lymphatics  may  occur  in  severe 
eases.  There  may  be  a  slight  lymphocytosis  in  the  early  stages,  and  if 
orchitis  occurs  leukocytosis  may  be  marked. 

The  duration  of  mumps  in  uncomplicated  cases  varies  from  one  to 
two  weeks.  Severe  cases  may  last  much  longer,  and  mild  afebrile  cases 
may  show  acute  symptoms  for  only  a  few  days. 

Complications. — In  childhood  this  disease  runs  a  much  milder  course 
than  it  does  in  adults,  and  the  complications  so  common  and  so  much 
dreaded  in  the  adult  are  rarely  seen.  For  this  reason  excellent  authorities 
have  advised  that  children  should  not  be  quarantined  from  this  disease, 
as  it  is  much  better  for  them  to  have  it  in  childhood  than  to  run  the  risk 
of  having  it  in  a  more  severe  form  in  adult  life. 

Orchitis,  the  most  common  and  dreaded  complication  in  adult  life, 
sometimes  occurs  in  boys  between  the  ages  of  twelve  and  fourteen ;  it  rarely 
occurs  earlier.  This  complication  usually  appears  about  the  end  of  the 
first  week  of  the  disease.  The  testicle  is  very  tender  and  may  be  swollen 
to  two  or  three  times  its  normal  size.  In  the  female  ovaritis  may  occur. 
In  both  sexes  there  may  be  enlargement  and  tenderness  of  the  breasts. 
Deafness  is  rare,  but  it  may  result  from  a  complicating  otitis  media. 
Albuminuria  is  not  infrequent,  but  nephritis  is  very  rare  in  childhood;  it 
occurs  more  frequently  in  adults.  Suppuration  of  the  parotid,  paralysis 
of  the  facial  and  auditory  nerves,  pancreatitis  and  inflammation  of  the  lac- 
rimal gland  are  almost  unknown  in  childhood. 

Diagnosis. — Mumps  must  be  differentiated  from  other  forms  of  paro- 


360  SYPHILIS 

titis,  and  the  physician  should  keep  in  mind  the  fact  that  inflammation  of 
this  gland  from  other  causes  is  not  very  uncommon.  It  may  occur  as  a 
complication  of  any  of  the  acute  infectious  diseases,  it  may  be  a  part  of 
a  general  septic  i)rocess,  it  may  be  secondary  to  stomatitis  and  catarrhal 
inflammation  of  Steno's  duct.  If  these  facts  are  kept  in  mind  the  differ- 
ential diagnosis  of  mumps  can  readily  be  made. 

Prognosis.  — This  is  almost  invariably  good.  In  older  children  com- 
plications may  leave  more  or  less  serious  results,  such  as  deafness  and 
impotency. 

Prophylaxis. — It  is  difficult  to  isolate  these  cases  except  during  the 
acute  stage,  but  for  a  period  of  three  weeks  from  the  beginning  of  the 
disease  they  should  not  be  allowed  to  return  to  school,  go  to  children's 
parties,  or  otherwise  come  into  close  contact  with  other  children. 

Treatment. — Mild  cases  require  no  treatment  beyond  confinement  to 
the  house  for  a  few  days.  In  the  more  severe  cases  the  patient  should  be 
kept  in  bed  for  a  period  of  eight  or  ten  days  covering  the  acute  symptoms. 
During  this  time  the  mouth  should  be  carefully  syringed  or  washed  out 
several  times  a  day  with  a  mild  alkaline  antiseptic.  The  parotid  swell- 
ing should  be  treated  with  hot  applications,  which  help  to  relieve  the 
pain  and  discomfort.  Ointments  containing  glycerin,  belladonna  and 
guaiacol  are  also  recommended.  Phenacetin  or  antipyrin  with  small  doses 
of  tincture  of  strophanthus  are  of  value  in  relieving  the  pain  and  rest- 
lessness. Chloral  h3'drate  is  a  valuable  hypnotic  in  this  disease,  and 
should  be  given  in  proper  doses  at  bedtime,  and  repeated,  if  necessary,  at 
three  or  four-hour  intervals  to  produce  sleep. 

"It  has  been  shown  that  urotropin  is  excreted  through  Steno's  duct. 
On  this  basis  it  should  be  of  value  in  the  treatment  of  mumps.  A  series  of 
cases  of  mumps  in  adults  at  the  Cincinnati  Hospital  was  treated  with  uro- 
tropin; none  of  these  developed  orchitis,  although  many  of  a  control  series 
treated  without  urotropin  did.  The  urotropin  cases  ran  a  uniformly  milder 
course  than  the  others."    (A.  Friedlander.) 

Dietetic  Treatment. — Acids  and  foods  which  irritate  the  mucous 
membrane  of  the  mouth  increase  the  pain  and  discomfort  and  should 
therefore  be  avoided.  Since  the  patient  may  have  difficulty  in  opening 
his  mouth  and  cannot  properly  masticate  his  food,  the  diet  should  con- 
sist of  milk,  gruels,  cereals,  ice-cream,  eggs,  milk-toast  and  other  soft  and 
liquid  foods. 

CHAPTEK    XLIII 

SYPHILIS 

Syphilis  is  an  acute  infectious  disease,  due  to  the  spirochseta  pallida. 
It  may  be  acquired  by  direct  contact  or  it  may  be  congenital.  The  acquired 
form  of  the  disease,  so  common  in  the  adult,  is  comparatively  rare  in  the 
child.    The  congenital  form,  which  is  the  ordinary  syphilis  of  infancy  and 


ETIOLOGY  361 

childhood,  is  characterized  by  cutaneous  eruptions,  by  general  malnutri- 
tion and  by  destructive  lesions  of  bones  and  internal  organs. 

Etiology. — The  specific  cause  of  this  disease  is  the  spirochseta  pallida, 
first  described  by  Schaudinn  in  1905.  This  organism  has  been  found  in 
the  various  lesions  of  both  the  acquired  and  congenital  forms  of  this  disease, 
such  as  the  initial  sore,  the  mucous  patches,  the  lymph  glands,  the  skin 
lesions  and  syphilis  of  the  internal  organs. 

Acquired  Syphilis. — Acquired  syphilis  in  infancy  and  childhood 
presents  the  same  clinical  picture  that  it  does  in  the  adult.  The  initial 
lesion,  which  is  followed  by  secondary  and  tertiary  symptoms,  is  contracted 
by  direct  contact  with  the  contagion.  Denuded  surfaces  of  skin  or  mucous 
membrane  on  the  infant  or  child  are  inoculated  with  the  specific  micro- 
organism of  this  disease  by  coming  in  contact  with  the  primary  sore  or 
mucous  patches  of  an  infected  individual.  In  older  children  it  may  be 
communicated  by  sexual  contact.  Acquired  syphilis,  however,  because  of 
its  comparative  rarity  and  the  sameness  of  the  clinical  picture  which  it 
presents  to  that  of  syphilis  in  the  adult,  requires  no  furth.er  consideration. 

Congenital  Syphilis. — Congenital  syphilis  is  essentially  a  disease  of 
infancy  and  childhood,  although  its  manifestations  may  continue  in  a 
modified  form  throughout  the  life  of  the  individual.  The  clinical  pic- 
ture of  this  form  differs  essentially  from  the  acquired  form  and  requires, 
therefore,  careful  clinical  study. 

Congenital  syphilis  can  be  transmitted  to  the  child  only  through  the 
mother,  and  the  virulence  of  the  infection  and  the  degree  of  syphilization 
of  the  fetus  depend  upon  the  virulence  and  stage  of  the  disease  in  the 
mother.  The  most  virulent  infections  occur  at  the  height  of  the  maternal 
secondary  stage;  as  this  stage  passes  into  the  tertiary,  the  infection  of  the 
fetus  becomes  less  virulent  and  less  certain.  In  the  very  early  primary 
and  the  well-advanced  tertiary  stages  the  syphilitic  taint  may  not  be  suffi- 
cient to  produce  syphilis  in  the  infant.  Previous  treatment  of  the  maternal 
parent  may  so  materially  modify  the  infection  of  the  offspring  that  it 
may  show  no  signs  of  the  disease,  but  the  recurrence  of  symptoms  and  re- 
lapses following  intermittent  treatment  in  the  mother  may  be  followed  by 
evident  syphilis  in  subsequent  children. 

For  many  years  it  was  very  generally  believed  that  syphilis  could  be 
transmitted  to  the  child  from  either  father  or  mother  or  from  both.  It 
was  thought  that  the  father  could  infect  the  ovum  directly  with  his  syph- 
ilized  sperm  and  the  mother  escape  subsequent  infection  through  the 
placental  barrier.  It  was  frequently  observed  that  these  children  with 
their  mucous  plaques  could  suckle  at  the  breast  of  their  mother  with 
impunity,  and  the  mother  escape  every  sign  of  infection;  a  wet  nurse, 
however,  not  previously  infected  with  syphilis  might  be  infected  by  these 
infants.  It  was  therefore  believed  that  the  mother  escaped  infection  and 
became  immunized  against  syphilis  through  her  syphilitic  offspring 
(Colics'  law).  It  was  also  observed  that  a  healthily  conceived  child  whose 
mother  became  infected  at  some  period  during  parturition    could  be  born 


362  SYPHILIS 

healthy  and  escape  infection  through  the  same  placental  barrier^  and  would 
remain  immune  against  syphilis  from  maternal  and  other  sources  (Profeta's 
law). 

The  Wassermann  reaction  has  demonstrated  that  both  infant  and 
mother  are  syi)hilized  under  these  conditions.  The  circulation  of  both 
mother  and  child  is  extremely  intimate,  the  placenta  presenting  no  barrier 
against  the  infection;  a  mother  who  produces  a  syphilitic  child  must  of 
necessity  share  the  infection,  and  her  immunity  and  that  of  her  child  is 
apparent,  not  real.  If  the  infected  mother  is  suffering  from  severe  mani- 
festations in  the  secondary  stage,  the  disease  would  probably  be  transmitted 
in  a  severe  form,  resulting  either  in  the  death  of  the  fetus  or  in  advanced 
congenital  syphilis. 

Syphilis  cannot  be  transmitted  to  the  third  generation.  The  physical 
defects,  however,  resulting  in  a  weak  progeny  may  be  transmitted,  but 
the  specific  lesions  of  this  disease  do  not  pass  to  the  third  generation. 

Pathology.- — Post-mortem  examination  of  a  macerated  syphilitic  fetal 
corpse  not  uncommonly  fails  to  show  any  characteristic  anatomical  changes 
of  this  disease.  This  is  especially  true  if  death  occurs  before  the  fourth 
month  of  .fetal  life.  After  the  fourth  month  the  characteristic  lesions 
commence  to  make  their  appearance,  osteochondritis  and  enlargement  of 
the  spleen,  liver,  kidneys,  pancreas,  thymus,  and  indurative  changes  in  the 
lungs  occur  with  increasing  frequency.  Skin  lesions  are  not  commonly 
found  until  near  the  end  of  the  normal  period  of  uterogestation. 

Syphilitic  osteochondritis  is  the  earliest,  most  common  and  most  char- 
acteristic lesion  of  congenital  syphilis.  It  occurs  principally  in  the  long 
bones  at  the  junction  of  the  shaft  with  the  epiphysis,  and  the  inflammation 
may  result  in  the  dissolution  of  this  junction,  thus  separating  the  epi- 
physis. The  enlargement  and  induration  of  the  spleen,  liver,  kidneys, 
lungs  and  pancreas,  so  commonly  present,  are  due  to  a  general  round- 
celled  infiltration  and  connective  tissue  proliferation. 

Symptomatology. — Syphilis  is  one  of  the  most  common  causes  of  re- 
peated abortions.  Following  an  abortion,  which  may  occur  as  early  as  the 
third  or  fourth  month,  producing  a  dead  and  macerated  fetus  showing  no 
distinctive  syphilitic  lesions,  the  same  woman  impregnated  by  the  same 
man  may,  one  or  two  years  later,  in  the  seventh  or  eighth  month  of  utero- 
gestation give  birth  to  a  dead  infant,  showing  an  osteochondritis  of  the 
long  bones,  enlargement  of  the  spleen  and  liver,  fatty  degeneration  of  the 
placenta,  round-celled  perivascular  infiltration  of  the  umbilical  cord  and 
other  characteristic  signs  of  congenital  syphilis.  One  or  two  years  later 
the  same  mother  may  give  birth  to  a  still-born  infant  at  term  or  to  one 
that  lives  but  a  few  days.  In  this  infant,  in  addition  to  the  signs  just 
noted,  the  kidneys,  lungs,  pancreas  and  other  internal  organs  may  show 
characteristic  syphilitic  lesions  and  the  skin  may  be  covered  with  a  large 
bullous  eruption  known  as  syphilitic  pemphigus.  Still  later  this  mother 
may  give  birth  to  an  infant  apparently  normal  at  birth  which,  within  tbe 
first  three  months,  develops  a  syphilitic  coryza  followed  by  other  signs 


SYMPTOMATOLOGY  363 

of  congenital  syphilis,  and  later  in  her  life  she  may  give  birth  to  an 
apparently  normal  child  which  never  shows  any  sign  of  syphilis.  This 
chain  of  clinical  manifestations  illustrates  the  fact  that  the  power  of 
transmitting  the  syphilitic  poison  is  gradually  lost  by  the  parents,  and 
also  that  in  direct  proportion  to  the  potency  of  the  poison  in  the  parents, 
the  earlier  and  the  more  virulent  will  the  manifestations  be  in  the  fetus, 
thus  producing  successively  in  the  same  mother  abortions,  premature 
births,  still-births  at  term,  syphilitic  weaklings  that  live  but  a  few  days, 
apparently  normal  infants  that  later  develop  syphilis,  and  finally  children 
in  whom  no  signs  of  syphilis  ever  develop. 

From  what  has  been  said  it  is  evident  that  the  earlier  the  manifesta- 
tions occur  after  birth  the  more  severe  the  disease  will  be.  Even  in  very 
early  syphilis  the  symptoms  are  not,  as  a  rule,  present  at  birth,  but  in 
quite  a  large  percentage  of  the  cases  the  disease  manifests  itself  during 
the  first  or  second  week.  In  these  early  cases  the  infant  is  profoundly 
malnourished,  and  as  the  disease  progresses  it  becomes  more  and  more 
wasted,  its  dried  skin  hanging  in  folds,  its  wizened  face  having  an  aged 
ajjpearance,  and  a  well-marked  coryza  discharging  an  irritating  fluid 
excoriates  the  upper  lip.  The  lips  are  cracked,  the  corners  of  the  mouth 
fissured,  and  mucous  patches  may  be  found  in  the  mouth  and  in  the  anus. 
A  bullous  eruption  appears  on  the  palms  of  the  hands  and  the  soles  of 
the  feet.  Tenderness  and  swelling  may  also  be  present  at  the  ends  of 
the  long  bones  near  the  joints  of  the  arms  and  legs.  External  and  in- 
ternal hemorrhages  may  occur  from  mucous  membranes.  In  the  worst 
cases,  as  the  disease  progresses,  the  emaciation  becomes  more  extreme  and 
the  child  dies  within  a  few  weeks.  Fortunately,  however,  in  the  great 
majority  of  cases  the  clinical  manifestations  do  not  develop  until  after 
the  middle  of  the  second  week  of  life,  and  from  this  time  until  the 
end  of  the  sixth  week  is  the  most  common  period  of  onset;  it  very 
rarely  develops  after  the  third  month.  These  cases  are  not  so 
violent  in  their  clinical  manifestations  and  are  much  more  amenable  to 
treatment. 

Coryza,  or  rhinitis,  is  the  commonest  and  most  characteristic  symp- 
tom, and,  as  a  rule,  marks  the  onset  of  the  symptom-complex.  The  mucous 
membrane  of  the  nose  is  intensely  irritated,  swollen,  and  discharges  a 
mucopurulent  fluid,  which  may  be  tinged  with  blood.  This  discharge  is 
irritating  in  character,  producing  an  eczema  of  the  upper  lip.  Crusts  form 
in  the  nasal  cavity,  which  have  a  tendency  to  retain  the  discharge,  and 
this  retained  discharge,  as  the  air  passes  through  it,  produces  a  snuffling 
sound  which  has  been  characterized  as  the  "snuffles."  With  the  formation 
of  crusts  and  the  retention  of  discharges  the  mucous  membrane  of  the 
nose  becomes  more  or  less  disintegrated,  and  the  cartilage  and  bones  of 
the  nose  become  involved.  If  this  process  continues  marked  nasal  de- 
formities may  result.  The  nasal  septum  may  be  perforated  and  the  bridge 
of  the  nose  may  be  broken  down,  producing  the  saddle  nose  and  other  de- 
formities.   A  severe  coryza  so  obstructs  the  nasal  passages  as  to  materially 


364  SYPHILIS 

interfere  with  the  infant's  nursing.  A  coexisting  laryngitis  may  produce 
hoarseness ;  this  is  a  very  suggestive  symptom. 

Skin  Lesions. — Vesicular  eruptions  are  very  rare  in  hereditary  syph- 
ilis, except  the  large  vesicular  or  bullous  eruption  known  as  syphilitic 
pemphigus,  which  occurs  in  the  severe  forms  of  this  disease  found  during 
the  first  weeks  of  life.  This  eruption  may  occur  over  the  body,  but  is 
commonly  confined  to  the  palms  of  the  hands  and  the  soles  of  the  feet,  and 
is  composed  of  large  blebs  from  an  eighth  to  one-half  inch  in  diameter, 
filled  with  bloody  fluid,  and  the  intervening  skin  where  the  eruption  is 
profuse  is  indurated  and  dark  red  in  color;  where  the  blebs  are  isolated 
a  zone  of  such  tissue  surrounds  them.  This  eruption  not  uncommonly 
causes  complete  exfoliation  of  the  skin  on  the  palms  of  the  hands  and 
the  soles  of  the  feet  and  is  most  ominous  in  its  significance,  as  it  occurs 
only  in  the  worst  cases.  It  is  not  to  be  confounded,  however,  with  non- 
syphilitic  pemphigus  neonatorum,  due  to  infection,  and  which  may  occur 
in  well-nourished  infants.  This  eruption  is  not  surrounded  by  a  reddish- 
brown  base,  and  does  not  select  the  palms  and  soles  as  its  favorite  site. 
Hochsinger  has  described  another  condition  of  the  skin  which  is  charac- 
teristic of  hereditary  syphilis  and  does  not  belong  to  the  acquired  form. 
The  skin  is  diffusely  infiltrated,  thickened  and  feels  dense  and  firm  to 
the  touch,  has  a  dark  red,  shiny  appearance,  getting  darker  in  color  as  it 
gets  older.  This  diffused  infiltration  of  the  skin  is  commonly  associated 
with  other  eruptions,  very  like  certain  of  the  eruptions  that  are  found  in 
the  acquired  form  of  syphilis.  These  eruptions,  like  the  pemphigus  erup- 
tion previously  described,  may  be  superimposed  upon  this  dark  red  in- 
durated skin.  Among  them  the  maculopapular  syphilide  is  the  most  com- 
mon. This  occurs  as  small,  round,  rose-red  spots  which,  as  they  grow 
older,  become  more  or  less  copper-colored,  and  are  elevated  above  the  sur- 
face of  the  skin.  A  distinctly  papular  eruption  may  be  associated  with 
this  macular  eruption,  the  small  papules  marking  the  center  of  the  rose- 
colored  macules,  or  appearing  as  a  separate  exanthem.  A  pustular  or  a 
papulopustular  syphilide  may  also  appear.  The  pustular  eruption  occurs 
most  commonly  on  the  face,  thighs  and  buttocks.  Mixed  eruptions  are 
very  common  in  hereditary  syphilis,  and  the  macular,  papular  and  pus- 
tular syphilide  may  all  be  present  at  the  same  time. 

Infiltration  of  the  skin  of  the  face  may  give  it  a  tense,  glittering 
appearance,  and  the  same  condition  may  exist  about  the  region  of  the 
anus.  This  leads  to  cracking  of  the  skin  and  the  formation  of  radial 
fissures  about  the  corners  of  the  mouth  and  the  anus,  which  produce  a 
more  or  less  characteristic  appearance  and  one  of  the  most  valuable  of 
diagnostic  signs.  Ulcers  and  mucous  patches  may  develop  in  these  fis- 
sures, greatly  increasing  the  irritation,  and  papular  excrescences  may  de- 
velop about  the  rectum,  producing  small  tumors  called  condylomata.  The 
infiltration  of  the  skin  about  the  finger  nails  produces  paronychia.  This 
may  be  an  active  ulcerative  process  about  the  root  of  the  nail,  or  it  may 
be  a  lower  grade  of  inflammation  unaccompanied  by  purulent  discharges. 


SYMPTOMATOLOGY 


365 


The  nail  may  be  destroyed  or  distorted.  This  same  process  affecting  the 
liairy  parts,  such  as  the  eyebrows  and  the  scalp,  may  result  in  the  complete 
destruction  of  hair  in  these  regions.  Complete  baldness,  however,  is  not 
very  common,  especially  in  early  infancy. 

Bones. — The  long  bones  may  be  tender  and  enlarged  near  their  ex- 
tremities, at  the  junction  of  the  shaft  and  the  epiphysis.  These  sensitive 
sw'ellings  occur  with  special  frequency  at  the  lower  epiphyses  of  the  hu- 
merus and  femur,  and  separation  of  the  epiphyses  may  result,  as  shown  by 
increased  motion  and  crepitus.  Associated  with  these  symptoms  there 
may  be  almost  entire  loss  of  motion  of  the  affected  limb.  This  is  spoken 
of  as  syphilitic  pseudo-paralysis,  and  is,  according  to  Hochsinger,  purely 
a  muscular  manifestation,  due  to  severe  periosteal  involvement  at  the 
point  of  muscular  attach- 
ment. According  to  the 
same  authority  syphilitic 
phalangitis  primarily  in- 
volves the  first  phalanges 
of  either  the  fingers  or  the 
toes.  The  fingers  are  most 
commonly  affected  and  the 
index  finger  is  its  favorite 
site.  Following  the  in- 
volvement of  the  proximal 
phalanx,  the  middle  pha- 
lanx of  the  same  finger  or 
toe  may  be  involved.  The 
swelling  thus  produced  is 
chronic  in  character,  coni- 
cal in  shape,  painless, 
tense,  and  glossy.  The 
soft  parts  are  but  slightly 
involved,  and  ulceration 
rarely  occurs. 

The  teeth  are  delayed,  imperfectly  developed  and  decay  early.  The 
skull  presents  more  or  less  characteristic  rachitic  changes  with  its  open 
fontanels  and  enlargement  of  frontal  and  parietal  eminences,  and  cranio- 
tabes  may  occur. 

General  Malnutrition. — The  degree  of  malnutrition  will  depend 
largely  upon  the  severity  of  the  disease  and  the  food  of  the  infant.  In 
the  severe  cases  developing  soon  after  birth  malnutrition  is  profound 
and,  as  previously  noted,  commonly  progresses  to  a  fatal  termination.  In 
the  later  and  less  severe  cases  the  child  at  birth  may  be  fairly  well  nour- 
ished and,  if  it  have  the  advantage  of  good  breast  milk  and  early  and 
proper  treatment,  it  may  continue  in  a  fair  state  of  nutrition.  Syphilitic 
babies,  however,  as  a  rule,  have  feeble  digestive  capacity,  and  those  that 
are  artificially  fed  show  a  more  or  less  marked  malnutrition,  which  may. 


Fig.  59. 


-Syphilitic    Dactylitis  ;    Infant    Sixteen 
Weeks  Old.     (Max  Dreyfoos.) 


366  SYPHILIS 

even  in  the  cases  that  develop  some  weeks  after  birth,  become  very  pro- 
nouncetl.  ^lalniitrition  is  associated  with  more  or  less  marked  anemia, 
which  may  be  characterized  in  severe  cases  by  a  diminution  in  the  amount 
of  hemoglobin  and  in  the  number  of  red  blood  corpuscles.  Many  of  the 
red  blood  corpuscles  are  nucleated  and  vary  greatly  in  size,  microcytes 
and  megalocytes  being  present.  There  is  also  a  more  or  less  marked 
leukocytosis  with  a  preponderance  of  myelocytes.  Eosinophils  are  also 
present.  General  lymph-node  enlargement  does  not,  as  ?  rule,  occur  in 
early  hereditary  syphilis. 

Brain. — Disease  of  the  brain  and  its  membranes  may  produce  hydro- 
cephalus, idiocy  and  hemiplegia. 

Spleen. — This  organ  is  very  much  enlarged  and  is  easily  palpated  in 
the  syphilis  of  early  infancy.  The  earlier  the  disease  develops  the  more 
pronounced  is  this  sign. 

Liver. — The  liver  may  be  enlarged,  extending  well  below  the  margin 
of  the  ribs;  jaundice  may  occur. 

Kidneys. — Acute  nephritis  may  occur  early  in  the  disease  and  yield  to 
specific  treatment.  It  is  also  a  late  manifestation,  occurring  shortly  before 
death.  In  these  cases  the  nephritis  may  be  a  terminal  lesion,  resulting 
from  the  intestinal  and  general  toxemia. 

Late  Hereditary  Syphilis. — Late  hereditary  syphilis  develops  later 
in  the  life  of  the  child,  usually  after  the  fifth  and  sometimes  as  late  as 
the  twelfth  or  fifteenth  year.  These  cases  present  the  symptoms  of  ordinary 
tertiary  syphilis.  They  are  commonly  believed  to  be  true  hereditary  syph- 
ilis, the  symptoms  of  which,  for  some  unexplained  reason,  were  not  clearly 
manifested  in  infancy.  The  small  minority  of  the  cases,  however,  may 
be  due  to  an  overlooked  syphilis  acquired  earlier  in  life.  In  calling  atten- 
tion to  these  cases  Hutchinson  described  the  following  triad  of  symptoms 
which  are  more  or  less  characteristic:  First,  the  notching  of  the  central 
incisor  teeth;  second,  an  interstitial  keratitis;  and  third,  sudden  deafness 
without  apparent  local  cause. 

Hutchinson's  Teeth. — The  central  incisors  of  the  secondary  teeth  have 
a  large,  single,  crescent-shaped  notch  occupying  the  center  of  each  tooth. 

The  teeth  themselves  are 
rounded  and  taper  from  a 
broad  base  to  a  constricted 
cutting  edge,  presenting  a 
peg-like  appearance.  They 
are  inclined  toward  each 
other,  as  a  rule,  but  occa- 
sionally they  may  diverge. 
When  present,  although  not 
Fm.  60.— Hutchinson's  Teeth.  absolutely   pathognomonic   of 

syphilis,  they  are.  when  taken 
in  connection  with  other  symptoms,  among  the  most  valuable  signs  of  this 
disease.    They  are  absent,  however,  in  a  majority  of  the  cases. 


DIAGJ^OSIS  367 

Interstitial  keratitis  may  be  associated  with  corneal  opacities  and  with 
inflammation  of  the  iris,  l)nt,  as  a  rule,  is  not  accompanied  by  an  active 
conjunctivitis.  This  symptom  is  also  especially  valuable  in  its  association 
with  other  symptoms  of  hereditary  syphilis. 

Sudden  loss  of  Jiearing  unaccompanied  by  apparent  disease  of  the  ear 
is  very  suggestive  of  hereditary  syphilis.  Loss  of  hearing  and  mastoiditis 
may  also  occur  in  this  disease,  resulting  from  a  low  grade  of  chronic 
otitis. 

Periostitis  of  the  tibia,  ulna,  radius,  and  humerus  may  occur.  The 
tibia  is  most  commonly  affected,  and  as  a  result  a  long,  narrow,  tender 
swelling  is  presented  on  its  anterior  surface. 

The  nose,  pharynx  and  palate  may  be  involved  in  destructive  ulcera- 
tions, causing  necrosis  of  the  underlying  bones,  and  marked  deformities 
may  result.  In  severe  cases  the  ulceration  in  the  nasopharynx  may  pro- 
duce widespread  destruction  of  the  tissues,  causing  the  bridge  of  the  nose 
to  give  way,  forming  the  so-called  saddle  nose. 

Gummatous  ulceration  may  occur  over  the  shin,  especially  of  the  face 
and  legs,  producing  large  round  ulcers  with  indurated  borders.  These  ul- 
cers have  a  tendency  to  group  themselves  and  in  their  healing  produce 
large  radiating  scars  which  are  more  or  less  characteristic.  This  is  espe- 
cially true  when  these  ulcers  involve  the  mucous  membrane  of  the  lips. 
Hochsinger  says:  "An  absolutely  positive  proof  of  former  hereditary 
syphilis  is  found  in  the  radial  scar  formation  of  the  lips." 

The  spleen  is  almost  always  notably  enlarged,  more  so  than  any  of  the 
other  internal  organs;  the  liver  may  be  increased  in  size.  There  is  a 
more  or  less  notable  enlargement  of  the  external  lymph  nodes;  in  this 
particular  late  hereditary  syphilis  differs  from  the  infantile  form. 

General  malnutrition  and  retarded  and  perverted  development  are 
among  the  notable  symptoms  occurring  in  late  childhood  about  the  period 
of  puberty. 

Diagnosis. — The  chief  difficulties  in  the  differential  diagnosis  of  early 
syphilis  are  presented  by  infantile  marasmus  and  tuberculosis.  In  infan- 
tile marasmus  the  malnutrition  commonly  occurs  later  in  the  life  of  the 
child,  and  there  is  perhaps  no  history  of  previous  abortions  and  snuffles. 
Enlargement  of  the  spleen  and  characteristic  syphilitic  skin  eruptions  are 
absent,  while  on  the  other  hand  there  is  perhaps  a  history  of  gastrointes- 
tinal disease  or  other  causes  which  may  explain  the  marasmus. 

Tuberculosis  of  the  bones  of  the  finger  and  of  the  long  bones  of  the 
arm  and  of  the  leg  may  be  mistaken  for  syphilis.  The  differential  diag- 
nosis may  here  commonly  be  made  by  the  family  and  personal  history  of 
the  child,  supplemented  by  the  tuberculin  skin  test.  Tuberculous  dactylitis 
involves  not  only  the  bone,  but  the  soft  parts  as  well,  producing  a  tender 
and  more  or  less  acute  inflammation  which  tends  to  suppuration  and  ul- 
ceration of  the  soft  parts.  In  these  particulars  it  differs  from  the  syph- 
ilitic dactylitis  previously  described.  In  the  long  bones  tuberculosis  in- 
volves the  epiphyses  rather  than  the  shaft  of  the  bones,  and  the  resulting 
25 


368  SYPHILIS 

inflammation  affects  the  joints,  while  in  syphilis  the  joints  are  not  com- 
monly involved  and  the  diaphyses  of  the  long  bones  are  the  sites  of  the 
inflammation. 

The  Wassermann-Neisser-Bruck  reaction  for  syphilis  is  the  most  exact 
method  of  differential  diagnosis.  To  make  this  test  accurately,  however, 
requires  special  training  and  laboratory  equipment.  A  detailed  descrip- 
tion of  its  technique  would,  therefore,  be  out  of  place  here,  but  a  brief 
allusion  to  its  fundamental  principles  and  their  practical  application  will 
not  be  amiss. 

Substances  called  antibodies  are  formed  in  the  serum  of  every  syph- 
ilitic who  in  any  way  reacts  against  the  infection.  They  are  constantly 
present  in  the  vast  majority  of  the  untreated  or  inadequately  treated  cases 
of  syphilis  in  all  stages  of  the  disease,  and  for  a  period  of  years.  These 
substances  preclude  hcmocytolysis  or  the  solution  of  the  sheep's  corpuscles  in 
the  Wassermann  reaction.  This  is  a  specific  reaction  for  syphilis,  and 
when  positive  is  an  unfailing  evidence  of  the  presence  of  the  disease.  It  is 
frequently  absent  in  well-defined  cases  of  severe  or  malignant  syphilis,  and 
in  such  cases  there  is  evidence  of  the  failure  of  the  system  to  properly 
react  against  the  ravages  of  the  affection.  It  gradually  disappears  in 
cases  that  have  received  adequate  medication,  and  in  such  cases  it  becomes 
the  best  scientific  evidence  we  possess  that  the  disease  is  under  control. 
Hereditary  syphilis,  according  to  Ledermann  and  numerous  others,  will 
often  show  a  positive  Wassermann  reaction  into  early  adult  life  or  later. 

In  view  of  the  now  generally  accepted  fact  that  a  syi)hilitic  infant  is 
of  necessity  progeniated  from  a  syphilized  mother  with  active  syphilis, 
a  Wassermann  examination  of  the  mother  confirms  or  rules  out  the  diag- 
nosis of  S3'philis  in  a  suspected  infant.  This  has  a  practical  application 
inasmuch  as  the  blood  for  the  examination  can  be  more  easily  obtained 
from  the  mother.  The  blood  may  be  secured  by  allowing  it  to  flow  through 
an  18-gage  needle  into  a  sterilized  centrifuge  tube  from  one  of  the  large 
veins  of  the  forearm,  after  an  Esmarch  bandage  has  been  placed  above  the 
elbow.  In  an  infant  the  blood  is  most  conveniently  collected  under  less 
favorable  and  less  aseptic  conditions  by  a  scarification  below  the  scapula. 

Prognosis. — The  earlier  the  symptoms  appear  the  worse  the  prognosis. 
The  more  severe  cases,  and  this  includes  a  large  percentage  of  the  total 
number,  die  in  utero,  and  of  those  that  are  born  alive  the  prognosis  is 
almost  uniformly  bad  when  the  symptoms  make  their  appearance  during 
the  first  week.  These  two  classes  include  in  the  neighborhood  of  50  per 
cent,  of  all  cases.  In  the  milder  cases,  in  which  the  symptoms  appear  af- 
ter the  second  week,  the  prognosis  under  proper  treatment  is  good  so  far 
as  life  is  concerned.  The  vast  majority  of  these  respond  quickly  to  the 
specific  medication  of  this  disease,  and  their  subsequent  chances  for  life 
will  depend  largely  upon  their  hygienic  surroundings  and  their  dietetic 
treatment.  Eelapses  occur  in  a  large  percentage  of  these  cases,  because  of 
insufficient  treatment.  It  is  also  probable  that  hereditary  syphilis  usually 
results  in  more  or  less  permanent  physical   deterioration.     The  degree. 


TREATMENT  369 

however,  of  this  deterioration  can  be  very  materially  modified  by  early  and 
persistent  treatment. 

Prophylaxis. — Individuals  affected  with  syphilis  should  not  marry  for 
four  years  after  the  beginning  of  the  disease,  and  then  only  after  at  least 
two  years  of  well-directed  medical  treatment.  If  married,  conception 
should  be  prevented  during  the  two  or  three  years  necessary  to  control 
this  disease.  If,  however,  conception  occurs,  the  mother  should  have 
antisyphilitic  treatment  throughout  the  entire  period  of  pregnancy.  In 
this  way  it  is  possible  to  largely  protect  the  fetus  and  cause  the  mother  to 
give  birth  to  an  apparently  healthy  child,  which  later  may  or  may  not 
show  signs  of  this  disease.  Special  stress  should  be  laid  upon  the  value 
of  giving  the  mother  antisyphilitic  treatment  in  all  cases  where  this  disease 
is  suspected.  This  is  especially  important  if  the  mother  at  any  time 
during  her  life  has  ever  been  actively  syphilitic.  With  the  birth  of  a 
syphilitic  infant  the  nurse  or  parents  should  be  impressed  with  the  fact 
that  the  infant  has  an  infectious  disease  which  may  be  communicated  to 
others.  Children  are  in  special  danger  from  kissing  and  from  using  the 
same  food  utensils.  The  danger  also  of  infection  to  a  non-syphilitic  wet- 
nurse  from  mucous  patches  in  the  mouth  of  the  infant  should  be  explained. 
The  danger  from  the  contagion  of  hereditary  syphilis  has  no  doubt  been 
greatly  exaggerated,  because  of  the  dread  of  this  disease.  But  although 
this  danger  may  be  slight,  there  is  no  reason  why  every  possible  precau- 
tion should  not  be  taken  to  prevent  the  infant  from  contaminating  others. 

Treatment. — Dietetic  Treatment. — The  dietetic  treatment  of  infan- 
tile syphilis  is  most  important.  Since  these  infants  have  feeble  digestive 
capacities  and  at  the  same  time  have  a  more  or  less  marked  malnutrition 
to  overcome,  it  is  all-important  that  they  should,  if  possible,  be  given 
breast  milk.  Fortunate  it  is,  therefore,  for  the  syphilitic  infant  that  its 
mother  may  nurse  it  with  comparatively  little  danger  to  herself.  The 
mother's  milk,  therefore,  should  be  used  in  every  instance  where  it  is  pos- 
sible, and  when  insufficient  should  be  supplemented  by  modified  milk  for- 
mulas suitable  to  the  age  and  digestive  capacity  of  the  infant,  and  these 
supplementary  feedings  should  be  carried  out  under  the  principles  outlined 
under  Mixed  Feeding.  That  is  to  say,  the  infant  is  to  be  given  the 
breast'  milk  at  every  nursing,  and  this  is  to  be  supplemented,  if  necessary, 
by  the  bottle.  In  those  cases  where  mother's  milk  is  not  available  it  may 
sometimes  be  necessary  in  order  to  save  the  life  of  the  infant  to  employ 
a  non-syphilitic  wet-nurse,  having  her  bring  her  own  infant  with  her  and 
giving  the  syphilitic  infant  such  breast  milk  as  can  be  obtained  by  pump- 
ing from  the  breast  of  the  wet-nurse.  Under  no  conditions,  however, 
even  though  the  mouth  of  the  syphilitic  infant  be  apparently  normal, 
should  it  be  allowed  to  nurse  the  milk  directly  from  the  breast  of  the  non- 
syphilitic  wet-nurse.  Great  importance  is  here  laid  upon  the  value  of 
breast  milk  in  the  treatment  of  this  disease,  because  I  believe  that  it  is 
necessary  to  complete  success  in  the  treatment  of  the  great  majority  of 
these  cases.    When,  however,  the  breast  milk  is  not  available  the  infant  is 


370  SYPHILIS 

to  be  fed  according  to  the  rules  laid  down  for  weaklings  under  Chronic 
Intestinal  Indigestion. 

Medical  Treatment. — Mercury. — Mercury  is  a  specific  for  this  disease, 
so  much  so  that  a  symptom  group  in  an  infant  over  three  weeks  of  age 
that  fails  to  respond  to  this  treatment  is  not  syphilitic.  This  therapeutic 
test  is  therefore  a  diagnostic  measure  of  great  importance. 

Inunction  of  Mercury. — In  the  young  infant  mercury  may  perhaps  be 
given  more  satisfactorily  by  inunction  than  by  any  other  method.  For  this 
purpose  unguentum  hydrargyri  mixed  with  anhydrous  lanolin  should  be 
used.  A  quantity  of  this  ointment  sufficient  to  represent  ten  or  fifteen 
grains  of  the  mercurial  ointment  is  to  be  used  for  each  inunction.  The 
site  of  the  inunction  should  be  prepared  by  carefully  cleansing  with  warm 
soap  and  water  and  then,  after  thoroughly  drying  the  skin,  the  mercurial 
ointment  is  to  be  gently  rubbed  in  for  from  five  to  eight  minutes,  the 
operator  using  rubber  gloves  in  making  the  inunction.  In  beginning  the 
routine  treatment  one  application  is  made  daily,  and  the  sites  commonly 
selected  are  the  inner  surfaces  of  the  thighs,  the  sides  of  the  chest  beneath 
the  axilla,  the  lower  abdomen  and,  if  necessary,  the  flexor  surfaces  of  the 
lower  arms  and  legs.  It  is  better  to  rotate  in  using  these  various  sites  for 
inunctions,  as  the  continuous  application  of  the  ointment  to  the  same  por- 
tion of  the  body  day  after  day  may  produce  an  irritation  of  the  skin.  In 
the  average  infant  the  specific  therapeutic  action  of  mercury  can  be  more 
quickly  and  more  satisfactoril}^  obtained  by  inunctions  than  by  any  other 
method,  and  its  administration  in  this  way  is  accompanied  by  no  gastro- 
intestinal disturbance.  These  facts  should  make  the  inunction  method 
the  method  of  election.  It  should  be  remembered,  however,  that  satis- 
factory results  can  be  obtained  only  by  carefully  following  the  technique 
as  above  outlined.  The  mercurial  ointment  should  be  diluted  with  lanolin 
and  should  be  thoroughly  rubbed  into  a  clean,  dry  skin.  Following  this 
application  the  child  may  have  a  bath  and  the  unsightly  ointment  removed 
from  the  skin.  This  is  sometimes  necessary  in  the  treatment  of  these 
cases  in  private  families  where  it  may  be  important  that  the  nature  of 
the  treatment  should  not  be  known  to  all  the  members  of  the  household. 

Internal  Administration  of  Mercury. — The  administration  of  mercury 
by  the  mouth  is  by  far  the  most  popular  method.  The  vast  majority  of 
cases  in  private  practice  are  treated  in  this  way,  because  almost  as  good 
results  can  be  obtained  by  this  method  and  because  it  is  so  easy  to  give 
mercury  in  this  manner.  For  this  purpose  four  preparations  are  in  com- 
mon use,  mercury  with  chalk,  calomel,  bichlorid  of  mercury  and  proto- 
iodid  of  mercury.  Of  these  mercury  with  chalk  is  the  favorite  with  the 
majority  of  English  and  American  pediatricians.  It  may  be  given  in  from 
one-half  to  one-grain  doses  two  or  three  times  a  day  to  young  infants.  The 
size  of  the  dose  may  vary  with  the  results  obtained  and  with  the  condition 
of  the  gastrointestinal  canal.  If  small  doses  are  being  given  (Yo  grain) 
and  the  symptom  group  does  not  yield  readily  to  treatment,  the  doses  are 
to  be  gradually  increased  to  1  or  114  grains,  and  in  oldex  children  to  2 


TREATMENT  371 

or  21  •>  grains.  When  the  symptom  group  has  been  controlled  it  is  better 
to  return  to  the  smaller  doses  for  the  long-continued  treatment  of  the 
disease.  This  rule  applies  in  the  administration  of  all  of  the  mercury 
preparations  whether  they  be  given  by  the  mouth  or  by  inunction.  The 
larger  dose  that  is  necessary  for  the  quick  control  of  the  early  symptoms, 
is  from  one-third  to  one-half  too  large  for  the  continued  administration  of 
this  drug  over  long  periods  of  time.  The  only  advantage  that  the  mercury 
with  chalk  has  over  the  bichlorid  and  protoiodid  is  that  it  commonly 
produces  less  gastrointestinal  disturbance  and  is  therefore  more  suitable 
for  long-continued  use.    This  applies  only  to  infants. 

The  bichlorid  of  mercury  may  be  given  to  infants  in  from  1/150  to 
1/200  of  a  grain,  well  diluted,  two  or  three  times  a  day.  The  total  quan- 
tity administered  in  twenty-four  hours  should  vary  from  1/100  to  1/40 
of  a  grain.  The  larger  dose  perhaps  being  required  to  control  the  acute 
symptoms,  and  the  smaller  dose  to  be  used  later  for  continuous  adminis- 
tration. The  protoiodid  of  mercury  is  used  very  largely  by  the  German 
school  of  pediatricians,  who  believe  that  better  results  are  obtained  from 
this  preparation  than  from  any  other.  It  may  be  given  in  doses  of  1/60 
of  a  grain  three  times  a  day. 

Calomel  is  a  remedy  of  great  value  in  beginning  the  treatment  of 
hereditary  syphilis,  and  it  is  asserted  by  some  authorities  that  the  initial 
specific  action  of  mercury  can  be  obtained  more  quickly  with  calomel  than 
with  any  other  preparation  of  this  drug.  It  may  be  given  in  1/10-grain 
doses  at  three  or  four-hour  intervals. 

Comparative  Value  of  the  Various  Mercurial  Preparations. — In  begin- 
ning the  treatment  it  is  perhaps  advisable  to  commence  with  calomel  in 
1/10-grain  doses  at  three-hour  intervals.  This  medication  may  be  con- 
tinued for  four  or  five  days,  or  until  decided  laxative  action  has  been  pro- 
duced. The  calomel  should  then  be  discontinued  and  followed  by  mer- 
curial inunctions  for  weeks  and  possibly  for  months,  until  the  syphilitic 
symptoms  are  under  control  and  the  nutritional  problems  have  been  largely 
solved.  Then  mercury  with  chalk  may  be  used  for  the  long-continued 
mercurial  course,  which  is  to  extend  with  interruptions  over  a  number 
of  years,  but  during  this  time,  if  gastrointestinal  disturbances  develop  and 
the  infant's  nutrition  is  thereby  threatened,  inunctions  are  again  to  take 
the  place  of  mercury  by  the  mouth.  In  older  infants  and  children  the 
bichlorid  or  protoiodid  of  mercury  may  be  substituted  for  the  chalk  mercury 
and  the  mercurial  ointment. 

lodin. — lodin  is  also  of  great  value  in  the  treatment  of  hereditary 
syphilis.  It  may  be  given  in  the  form  of  iodid  of  potassium,  iodid  of 
sodium  and  iodonuclcoids.  The  iodonucleoids  will  not  disturb  the  stomach 
and  are  therefore  of  special  value  in  young  infants.  It  may  be  combined 
with  equal  parts  of  saccharated  pepsin  or  milk  sugar  and  given  in  1  or  2- 
grain  doses  three  times  a  day ;  this  may  be  increased  1  grain  for  each  year 
of  life  up  to  four  years.  Iodid  of  potassium  dissolved  in  milk  or  essence 
of  pepsin  may  be  administered  to  infants  in  2-grain  doses  three  times  a 


372  SYPHILIS 

day.  In  children  five  or  six  years  of  age  this  dose  may  be  increased  to  5 
or  10  grains.  The  iodid  of  potash  is  on  the  whole  the  best  form  for 
administering  iodin  in  these  cases.  But  if  it  should  cause  gastric  disturb- 
ance iodonucleoids  may  be  substituted.  The  iodids  are  especially  indi- 
cated in  late  hereditary  syphilis,  but  they  may  also  be  indispensable  in  the 
treatment  of  infantile  syphilis  when  gummatous  ulcerations  and  bone  le- 
sions are  present. 

Duration  of  Treatment. — It  has  for  many  years  been  my  practice  to 
give  mercury  with  short  interruptions  during  the  first  year,  and  for  about 
half  the  time  during  the  second  year.  After  the  second  year,  as  a  matter 
of  routine,  a  course  of  iodids  should  be  occasionally  administered  to 
alternate  with  a  course  of  mercury,  and  this  should  be  continued  until  the 
child  is  four  or  five  years  of  age.  These  courses  should  be  of  six  weeks' 
duration  and  should  be  given  only  two  or  three  times  during  the  year. 
After  the  fifth  year  the  treatment  should  be  resumed  on  the  appearance  of 
chronic  obscure  symptoms  of  any  kind.  If  at  any  time  pronounced  and 
active  symptoms  of  syphilis  reappear,  vigorous  and  prolonged  antisyph- 
ilitie  treatment  must  again  be  instituted.  The  long-continued  interrupted 
use  of  mercury  and  the  iodids  produces  no  bad  results  on  the  teeth  or 
other  developing  structures. 

Salvarsan. — Salvarsan  has  proved  very  efficacious  in  the  treatment  of 
congenital  syphilis.  The  mortality  of  this  disease  in  the  new-born  has 
been  materially  reduced  by  the  introduction  of  this  remedy.  Under  it 
the  gain  in  weight  and  marked  improvement  in  general  appearance  of  the 
infant  have  been  as  noteworthy  as  the  rapid  disappearance  of  active  symp- 
toms. The  administration  of  this  remedy  to  infants  is  attended  with  tech- 
nical difficulties.  The  intravenous  and  deep  muscular  injections  with  al- 
kaline solutions  are  impracticable.  The  freshly  precipitated,  carefully 
neutralized  salt  of  salvarsan  must  be  injected  subcutaneously.  These  in- 
jections are  fairly  well  tolerated,  although  they  produce  painful  infiltra- 
tions and  occasionally  form  abscesses  and  indolent  ulcerations  of  the  over- 
lying skin. 

Six  decigrams  of  salvarsan,  under  careful  aseptic  precautions,  are  dis- 
solved in  a  clean  mortar  with  thirty-five  drops  of  sterile  10  per  cent, 
sodium  hydroxid  solution ;  this  is  then  diluted  up  to  12  c.  c.  with  normal 
salt  solution.  Then  two  to  six  grams  varying  with  the  age,  weight  and 
development  of  the  child  (one  to  ten  years,  one  to  three  decigrams  of  sal- 
varsan) are  drawn  off  with  a  sterile  pipette  into  a  second  sterile  mortar.  A 
few  drops  of  concentrated  glacial  acetic  acid  are  then  added  with  gentle 
stirring  until  the  color  is  changed  from  red  to  light  yellow,  and  neutrality 
is  established;  this  can  be  determined  by  means  of  sterile  litmus  paper. 
It  is  then  diluted  to  about  10  c.  c.  with  sterile  normal  salt  solution,  trans- 
ferred to  a  centrifuge  tube,  and  centrifuged  for  five  minutes.  The  clear 
supernatant  liquid  is  then  carefully  drained  away  and  the  residue,  after 
it  is  again  diluted  with  5  to  10  c.  c.  of  sterile  normal  salt  solution,  is 
transferred  to  a  syringe  and  injected  subcutaneously  under  the  scapula. 


ETIOLOGY  373 

In  view  of  the  fact  that  the  administration  of  salvarsan  is  occasionally 
attended  with  relapses,  it  is  advisable,  in  the  absence  of  careful  Wasser- 
mann  control,  to  supplement  the  administration  of  this  remedy  with  inter- 
mittent treatment  along  the  lines  of  the  older  accepted  methods.  It  is  also 
advisable  not  to  repeat  the  salvarsan  under  a  period  of  at  least  three  or 
four  months. 

Local  Treatment. — Local  treatment  of  syphilitic  ulcerations  demands 
the  careful  cleansing  with  antiseptic  washes  and  the  use  of  a  dusting 
powder  composed  of  equal  parts  of  calomel,  subnitrate  of  bismuth  and 
oxid  of  zinc. 

CHAPTER    XLIV 
TUBERCULOSIS 

Etiology. — Tuberculosis  is  a  contagious  disease  caused  by  the  bacillus 
tuberculosis  of  Koch.  It  may  be  general,  but  is  commonly  more  or  less 
localized,  there  being  one  or  more  foci  of  infection.  It  has  a  great  predilec- 
tion in  childhood  for  the  lymph  nodes,  bones,  and  serous  membranes,  but 
no  part  of  the  body  is  exempt  from  attack. 

There  are  a  number  of  fairly  distinct  types  of  tubercle  bacilli ;  of  these 
we  are  especially  interested  in  the  human  and  bovine,  since  they  may  pro- 
duce tuberculosis  in  man.  The  human  type  is  the  most  common  cause  of 
all  forms  of  tuberculosis  in  the  child  as  it  is  in  the  adult,  but  bovine  tu- 
berculosis is  relatively  much  more  common  in  children,  and  is  not  an  in- 
frequent cause  of  this  disease  in  the  cervical  and  abdominal  lymph  nodes 
and  in  the  peritoneum.  The  human  type  is  the  usual  cause  of  the  more 
virulent  forms  of  tuberculosis,  while  the  bovine  type,  as  a  rule,  produces 
a  milder  form  of  this  disease. 

Contagion. — Contagion  is  the  all-important  factor  in  the  spread  of 
tuberculosis.  Tubercle  bacilli  are  discharged  from  the  body  of  a  tubercu- 
lous individual  in  a  moist  state,  in  the  sputum,  the  milk,  the  feces,  the 
urine,  and  in  the  purulent  discharges  from  tuberculous  abscesses  and  ul- 
cerations. Of  these  various  discharges  the  sputum  is  by  long  odds  the  most 
important  agent  in  spreading  the  infection,  and  for  this  reason  the  pul- 
monary form  of  tuberculosis  is  the  chief  source  of  contagion.  The  danger 
from  tuberculous  sputum  is  very  great  in  both  the  moist  and  the  dried 
state.  The  dried  bacilli  are  much  more  widely  disseminated  than  the  moist 
bacilli,  but  the  latter  are  much  more  active  and  virulent  and  a  smaller 
dosage  is  therefore  required  to  set  up  an  active  tuberculosis.  In  their  moist 
state  the  tubercle  bacilli  are  thrown  in  a  fine  spray  for  a  distance  of  eight 
or  ten  feet  by  coughing,  and  may  thus  be  inhaled  by  those  who  come  within 
the  range  of  this  infection.  In  this  manner  and  also  by  the  careless 
disposal  of  the  expectoration,  the  clothing  and  surroundings  of  the  patient 
may  become  infected;  handkerchiefs,  wearing  apparel,  carpets,  hangings 
and  bed-clothing  may  be  carriers  for  a  short  time  of  the  bacilli  in  a  moist 


374  TUBERCULOSIS 

state,  and  therefore  a  source  of  great  clanger,  especially  to  infants  and  young 
children  who  spend  a  great  portion  of  the  time  in  such  contaminated 
apartments.  Their  milk  and  other  food,  which  is  too  often  prepared  in 
such  surroundings,  may  hecome  contaminated,  and  act  as  a  vehicle  for 
carrying  the  tubercle  bacilli  into  their  intestinal  canals.  Another  danger 
from  the  moist  sputum  lies  in  the  fact  that  flies  and  other  insects  may 
be  a  means  of  transferring  bacilli  to  remote  parts  of  the  house  and  pro- 
ducing food  contamination.  Infants  with  the  inherent  instinct  which  they 
have  of  putting  everything  into  their  mouths  are  in  special  danger,  since 
their  toys  and  other  foreign  bodies  with  which  they  come  in  contact  may 
carry  into  their  mouths  the  moist  tubercle  bacilli. 

But  after  all  the  greatest  danger  in  the  spread  of  tuberculosis  lies  in 
the  fact  that  the  slender,  rod-shaped  bacillus  of  this  disease  is  small  and 
light  enough  to  be  carried  short  distances  in  a  dried  state  by  dust,  or  other 
foreign  particles  put  in  motion  by  currents  of  air,  and  thus  be  inhaled  or 
produce  food  contamination.  This  in  fact  is  an  ever-present  danger  in 
public  conveyances  and  in  buildings  now  housing  or  that  have  housed  tu- 
berculous patients. 

Next  to  sputum,  milk  contaminated  with  tubercle  bacilli  is  the  most 
potent  factor  in  the  spread  of  this  disease.  There  is  no  longer  any  doubt 
but  that  milk  from  tuberculous  cattle  may  be  a  source  of  danger,  especially 
to  infants,  and  the  milk  of  the  tuberculous  mother  may  also  be  a  carrier 
of  tubercle  bacilli.  But  in  milk  the  greatest  danger  comes  from  localized 
tuberculous  disease  of  the  udder  of  the  cow,  or  some  other  method  of  out- 
side milk  contamination,  rather  than  through  the  excretion  of  tubercle 
bacilli  in  milk. 

The  urine,  the  feces  and  purulent  discharges  from  tuberculous  patients 
may  be  sources  of  infection,  although  this  danger  is  believed  to  be  slight 
because  of  the  great  dilution  of  the  bacilli  and  because  of  the  manner  in 
which  these  discharges  are  ordinarily  disposed  of. 

Portals  of  Entry. — Tuberculous  infection  enters  the  body  through  the 
nasopharynx,  the  bronchial  mucous  membranes  and  the  digestive  tract. 
This  latter  route  is  much  more  common  in  the  child  than  in  the  adult.  The 
passage  of  tubercle  bacilli  through  mucous  membranes  may  be  effected 
without  producing  injury  or  disease  of  the  parts  through  which  they  pass. 
The  accidental  contamination  of  vaccination,  circumcision  and  other  fresh 
wounds  can  only  occur  where  gross  carelessness  leads  to  direct  inoculation, 
and  this  is  fortunately  a  very  rare  occurrence. 

Exposure. — Tuberculosis  is  such  a  pandemic  disease  that  practically 
every  individual  is  exposed  many  times  to  its  contagion.  But  this  does 
not  militate  against  the  fact  that  the  greatest  danger  comes  from  repeated 
exposure  to  the  contagion  in  places  especially  infected  with  tubercle  bax3illi. 
In  other  words,  one  may  say  that,  other  things  being  equal,  the  danger 
of  contracting  tuberculosis  is  in  direct  proportion  to  the  frequency  and  size 
of  the  dose  of  the  contagion.  This  is  a  fact  that  should  be  impressed  with 
especial  force  on  the  minds  of  the  laity,  since  to  them  the  contagion  is 


ETIOLOGY  375 

not  apparent,  inasmuch  as  active  symptoms  do  not  commonly  develop,  in 
infants  and  yonng  cliildren,  until  long  enough  after  the  exposure  to  the 
contagion  for  them  to  fail  to  see  and  recognize  the  connection  between 
the  exposure  and  the  subsequent  development  of  tuberculosis.  If  active 
tuberculosis  followed  as  quickly  upon  exposure  to  the  contagion  as  do 
diphtheria  and  scarlet  fever,  the  laity  would  then  quickly  recognize  the 
fact  and  insist  upon  such  measures  of  isolation,  quarantine  and  disinfec- 
tion as  would  greatly  reduce  the  prevalence  of  this  disease. 

Tuberculosis  is  very  rarely  contracted  in  utero  by  direct  transmission 
through  a  tuberculous  placenta;  about  forty  such  cases  have  been  reported. 
It  is  not  proven,  however,  that  this  disease  can  be  transmitted  by  tuber- 
culosis of  the  spermatozoa  of  the  male  or  the  ovum  of  the  female  without 
the  intervention  of  a  tuberculous  placenta. 

Heredity. — Heredity  has  from  the  earliest  times  been  believed  to  be 
a  most  important  factor  in  producing  tuberculosis.  At  present,  however, 
in  the  sense  that  one  means  that  the  patient  has  inherited  a  specific  sus- 
ceptibility to  tuberculosis,  heredity  is  believed  to  be  a  very  unimportant 
predisposing  factor,  that  is  to  say  the  special  tuberculous  diathesis  which 
was  supposed  to  furnish  a  favorable  soil  for  the  tubercle  bacillus,  while  not 
wholly  a  negligible,  is  a  comparatively  unimportant  factor  in  its  spread. 
The  hereditary  factor  is  not  so  much  a  specific  tendency  to  this  disease 
as  it  is  a  weak  constitution  which  belongs  to  the  puny  offsprings  of  weak 
and  tuberculous  parentage.  Children  of  this  class  are  usually  anemic, 
malnourished  and  unable  to  offer  the  normal  resistance  to  the  tubercle 
bacillus.  The  question  therefore  of  family  tuberculosis  is  largely  a  matter 
of  infection.  Over  50  per  cent,  of  all  patients  with  this  disease  give  a 
history  of  other  cases  in  the  family.  All  children  inherit  a  defensive 
mechanism  which  enables  them,  under  favorable  conditions,  to  combat  more 
or  less  successfully  the  contagion  of  tuberculosis.  This  defensive  mechan- 
ism, which  is  very  weak  in  infancy,  becomes  gradually  stronger  as  the 
child  grows  older.    It  may  be  weakened  by  inheritance  or  by  disease. 

Acute  Infectious  Diseases. — Acute  infectious  diseases,  especially 
those  which  involve  mucous  membranes  and  produce  lymph-node  enlarge- 
ment, such  as  measles,  whooping-cough,  influenza  and  enteritis,  are  very 
important  predisposing  factors  in  preparing  the  soil  for  tuberculous  in- 
fection, and  are  also  important  in  developing  a  latent  into  an  active  tuber- 
culosis. 

Poverty. — Tuberculosis  is  one  of  the  greatest  causes  of  poverty.  Com- 
paratively prosperous  families  of  the  working  class  are,  within  a  short 
period  of  time,  reduced  to  abject  poverty  by  reason  of  the  fact  that  the 
productive  member  of  the  family  is  incapacitated  from  work  by  this  dis- 
ease. This  leads  to  bad  hygienic  surroundings,  insufficient  food,  over- 
crowding and  the  rapid  dissemination  of  tuberculosis  among  the  other, 
and  especially  the  younger,  members  of  the  family.  Here  the  poverty 
caused  by  tuberculosis  becomes  a  most  important  factor  in  its  dissemina- 
tion.    The  winter  season,  by  crowding  poor  families  into  dark  and  un- 


376  TUBEECULOSIS 

wholesome  surroundings,  deprives  them  of  sunlight  and  fresh  air  and 
promotes  the  spread  of  this  disease  by  diminishing  the  normal  resistance 
of  the  child  and  increasing  its  opportunities  for  contagion. 

School  Infection, — School  infection  is  not  as  great  a  factor  in 
spreading  tuberculosis  as  it  is  in  disseminating  other  contagious  diseases. 
The  protection  here  lies  in  the  fact  that  a  very  great  majority  of  the  cases 
of  tuberculosis  in  childhood  are  not  characterized  by  active  pulmonary 
symptoms,  are  not  accompanied  by  the  expectoration  of  tuberculous  sputum, 
and  are  therefore  not  anything  like  so  contagious  as  they  are  in  adults, 
in  whom  the  open  pulmonary  form  is  the  common  type  of  the  disease. 

Age. — Age  is  the  most  important  of  all  the  predisposing  factors.  The 
great  majority  of  the  cases  of  tuberculosis  are  contracted  in  childhood, 
even  though  the  active  symptoms  may  not  occur  until  much  later  in  life. 
The  normal  adult  is  practically  immune  from  this  infection ;  the  vast  ma- 
jority of  the  cases  of  adult  tuberculosis  are  the  result  of  infection  in  child- 
hood. Infancy  is  the  most  susceptible  of  all  ages  and  perhaps  there  is  no 
such  thing  as  immunity  during  this  period  of  life.  If  the  young  infant 
is  repeatedly  exposed  to  the  contagion  it  will  almost  surely  contract  the 
disease,  and  yet  the  first  few  months  of  life  show  comparatively  few  cases. 
This  may  perhaps  be  due  to  the  facts  that  during  this  time  the  opportunities 
for  infection  are  less,  and  the  breast  milk  upon  which  most  infants  are  fed 
confers  a  partial  immunity.  As  the  child  grows  older  its  power  of  re- 
sisting the  tuberculous  infection  becomes  greater,  and  the  disease  when 
contracted  usually  runs  a  much  less  virulent:  course.  The  increasing  re- 
sistance of  the  tissues  of  the  child  to  tuberculous  processes  does  not  result 
in  less  frequent  infection,  but  it  does  result  in  localizing  and  diminishing 
the  severity  of  tuberculous  processes.  The  mortality  returns  do  not  give 
a  correct  idea  of  the  prevalence  of  tuberculosis  at  different  ages  in  children. 
In  infancy  the  death  rate  is  high,  and  represents  a  large  percentage  of  all 
the  cases  occurring  at  this  age;  latent  and  chronic  forms  of  the  disease 
rarely  occur  in  infants.  In  childhood  the  death  rate,  compared  with  the 
number  of  cases,  is  small;  at  this  age  most  of  the  cases  are  chronic,  and 
the  disease  may  last  for  years.  During  childhood  the  prevalence  of  tuber- 
culosis gradually  increases,  and  the  severity  of  the  disease  gradually  di- 
minishes; the  prevalence  increases  more  rapidly  and  the  severity  diminishes 
more  rapidly  during  the  first  three  years  of  life  than  later.  The  frequency 
of  tuberculosis  in  childhood  has  been  a  matter  of  much  speculation  since 
the  mortality  returns  cannot  be  depended  upon  to  determine  the  prevalence 
of  this  disease  during  this  period  of  life. 

It  is,  however,  generally  admitted  that  at  least  20  per  cent,  of  all  chil- 
dren living  in  cities  have  tuberculosis  in  a  more  or  less  active  form.  In 
many  of  these,  however,  the  disease  is  running  a  very  insidious  course  in 
the  deep-seated  lymphatic  glands.  Tuberculin  skin  reactions  indicate  that 
a  much  larger  percentage  carry  tuberculous  foci  in  a  latent  form;  these 
cases  may  present  absolutely  no  clinical  symptoms.  Examinations  made  at 
dispensary  clinics  and  institutions  for  the  care  of  children  show  that,  among 


PATHOLOGY  377 

the  children  of  the  poor,  from  60  to  80  or  90  per  cent,  react  to  the  tuber- 
culin skin  tests ;  this  determines  the  enormous  prevalence  of  latent  tubercu- 
losis in  childhood.  ^  In  1895  the  author  wrote  as  follows :  "Concealed 
lymph-node  tuberculosis  is  the  characteristic  tuberculosis  of  childhood  and  is 
more  prevalent  than  all  the  chronic  diseases  of  childliood  taken  together. 
It  is  all  about  us  every  day;  in  our  asylums,  our  schools,  and  our  homes, 
masquerading  as  a  preturberculous  condition,  as  anemia,  neurasthenia, 
lithomia,  malaria  and  other  ill-defined  conditions;  but  in  the  meantime  it' 
progresses  apace,  and  too  often  only  casts  off  its  disguise  after  irreparable 
damage  has  been  done." 

Pathology. — The  tubercle  bacilli  find  their  way  into  the  body  through 
the  portals  of  entry  previously  described,  and  in  infancy  and  early  child- 
hood usually  find  lodgment  in  the  bronchial,  cervical  or  mesenteric  lym- 
phatic glands.  Here  they  may  be  destroyed,  or  they  may  at  once  set  up 
an  active  tuberculosis  either  at  the  point  of  entry  or  in  some  distant  part 
of  the  body  or,  what  is  much  more  common,  they  may  remain  for  months 
or  years  either  dormant  or  in  a  slow  state  of  incubation,  until  favorable 
conditions  cause  them  to  develop  an  active  tuberculous  inflammation. 

The  initial  and  characteristic  lesion  produced  by  the  tubercle  bacillus 
is  the  miliary  tubercle,  which  is  a  minute  grayish,  translucent,  firm  nodule, 
about  the  size  of  a  millet  seed,  which  can  be  rather  readily  seen  with  the 
naked  eye.  They  are  made  up  of  epithelioid  cells  often  arranged  in  con- 
centric layers,  with  occasional  giant  cells  in  their  center ;  no  vascular  struc- 
tures have  been  observed  in  them ;  tubercle  bacilli  are  found  in  and  among 
these  cells.  Under  the  influence  of  these  bacilli,  the  tubercles  multiply 
in  number,  become  the  center  of  active  inflammatory  changes,  coalesce,  and 
the  oldest  tubercles  increase  in  size  and  commence  to  undergo  a  central 
necrosis  which  gradually  transforms  them  into  a  cheesy  mass.  The  spread 
of  the  tuberculous  process  may  then  occur  by  continuity  and  contiguity  of 
tissues  to  neighboring  parts,  or  by  lymph  and  blood  channels  to  more 
distant  organs,  thus  producing  the  various  forms  of  tuberculosis  in  infancy 
and  childhood.  A  short  sketch  of  the  individual  pathological  lesions  of 
these  various  types  of  tuberculosis  here  follows: 

Lympii-Node  Tuberculosis. — Lymph-node  tuberculosis  is  by  far  the 
most  common  form  in  infancy  and  childhood.  The  initial  lesion  in  the 
vast  majority  of  instances  not  only  begins  in  these  glands  but  usually  re- 
mains there  for  some  time  before  the  infection  spreads  to  other  tissues. 
The  bronchial  lymph  nodes  are  of  vastly  greater  importance  as  tuberculous 
foci  because  they  are  more  frequently  affected  than  any  other  lymph  nodes 
in  the  body  and  because  disease  of  these  glands  is  of  much  more  serious 
import  in  the  spread  of  the  disease  to  other  and  more  vital  tissues  and 
because,  by  reason  of  their  location  in  the  bony  cavity  of  the  chest,  their 
enlargement  may  produce  severe  pressure  symptoms  on  the  blood  vessels, 
nerves  and  bronchi  with  which  they  are  in  close  association.  The  bronchial 
lymph  nodes,  anatomically  described  as  peritracheo-l)ronchial  glands,  are 
^New  York  Medical  Journal,  August  10,  1895. 


378  TUBERCULOSIS 

divided  into  three  groups.  The  first  group,  or  tracheal  glands,  are  situated 
on  both  sides  of  the  traehea,  beginning  on  the  riglit  side  in  the  angk^  of 
the  trachea  and  right  bronchus ;  they  ascend  along  the  trachea  to  the  sub- 
clavian vessels  and,  beginning  at  a  corresponding  point  on  the  left  side 
of  the  trachea,  they  ascend  to  the  arch  of  the  aorta  and  the  recurrent 
laryngeal  nerves.  These  glands  are  in  relation  with  the  arch  of  the  aorta, 
the  recurrent  laryngeal  and  pneumogastric  nerves,  the  pulmonary  artery 
and  the  superior  vena  cava.  The  second  group  is  situated  in  the  angle 
formed  by  the  bifurcation  of  the  trachea  and  extends  along  the  large 
bronchi.  They  are  in  relation  with  the  large  bronchi,  especially  on  the 
right,  and  with  the  esophagus,  aorta  and  pneumogastric  nerve.  The  third 
group  extends  along  the  bronchi  into  the  lungs;  they  are  associated  with 
groups  of  glands  in  the  angles  of  the  bifurcation  of  the  large  bronchi  as 
far  as  the  fourth  bifurcation,  and  with  the  veins  and  arteries  which  ac- 
company the  bronchi  into  the  limgs.  The  anterior  mediastinal  lymph 
nodes  are  in  relation  with  the  right  innominate  artery,  the  right  sulx'lavian 
artery,  and  the  arch  of  the  aorta,  and  the  posterior  mediastinal  lymph 
nodes  are  in  relation  with  the  esophagus  and  aorta.  The  cervical  lymph 
nodes  are  very  abundant  and  are  in  close  association  with  the  large  ves- 
sels and  nerves  of  the  neck,  but  these  nodes  have  little  direct  communication 
with  the  bronchial  nodes,  and  their  enlargement  rarely  produces  pres- 
sure symptoms  because  they  are  not  confined  in  a  bony  cavity.  The 
superficial  cervical  lymph  nodes  below  and  behind  the  external  ear  and  over 
the  upper  portion  of  the  sternomastoid  muscle,  and  the  deeper  cervical 
lymph  nodes,  in  relation  with  the  jugular  veins,  above  and  behind  the 
clavicle,  are  commonly  the  site  of  tuberculous  lesions.  The  mesenteric 
lymph  nodes  are  very  widely  disseminated  through  the  abdominal  cavity 
and  are  in  close  association  with  the  large  nerves  and  blood  vessels  as  well 
as  with  certain  portions  of  the  large  intestine.  A  notable  group  is  situated 
in  the  region  of  the  appendix  which  is  not  uncommonly  enlarged  in  mesen- 
teric tuberculosis  and  forms  a  readily  palpable  tumor.  The  mesenteric 
lymph  nodes,  being  unconfined  by  bony  walls,  do  not  usually  by  their  en- 
largement produce  pressure  symptoms  on  the  blood  vessels  and  nerves 
with  which  they  are  in  contact.  But  these  nodes,  unlike  the  cervical  ones, 
are  in  close  communication  through  lymph  channels  with  the  bronchial 
nodes,  so  that  a  tuberculous  infection  of  these  glands  commonly  leads  to 
a  secondary  infection  of  the  bronchial  glands.  On  the  other  hand,  bron- 
chial lymph-node  tuberculosis  does  not  so  commonly  lead  to  infection  of 
the  mesenteric  glands;  this  is  perhaps  explained  by  the  direction  of  the 
lymph  stream. 

The  agglutination  and  caseation  of  tubercles,  with  the  resulting  in- 
flammatory changes,  may  cause  great  enlargement  of  lymph  nodes  and 
necrosis  of  lymphatic  tissues.  This  destruction  gradually  involves  neigh- 
boring nodes  and  the  intima  of  adjacent  lymph  and  blood  vessels.  In 
this  manner  masses  varying  in  size  from  a  pea  to  a  hen's  egg  may  be  formed, 
producing  mechanical  as  well  as  septic  symptoms.     An  important  fact  in 


PATHOLOGY 


379 


the  pathology  of  lymph-node  tuberculosis  is  that,  even  after  the  deep-seated 
bronchial  and  mesenteric  lymph  nodes  have  undergone  more  or  less  casea- 
tion, nature,  as  a  rule,  succeeds  in  encapsulating,  absorbing,  and  calcifying 
them,  thus  preventing  further  infection  by  the  discharge  of  tuberculous 
pus  through  ulceration  into  the  blood  vessels,  the  bronchi,  the  trachea,  the 
esophagus,  the  pleura,  the  pericardium,  the  peritoneum,  or  the  surround- 
ing cellular  tissues.  While  all  of  these  may  occur  they  are  comparatively 
uncommon,  and  rwovery  without  ulceration  after  caseation  of  deep-seated 
lymph  nodes  is  the  rule  rather  than  the  exception;  but  caseation  of  ex- 


Thyroid  gland 
Gl.  aubmaxill. 
Trachea 
Asc.  aort; 
Gl.  traeh.-asophag. 
Gl.  subclavical. 

CI.  mediatt.  ant 

Vena  cava  suoerior. 

Gl.  irach.-bronch. 

Gl.  pulmonales.' 

Bronchi 

Gl.  pleuropulmon.. 

Thoracic  duct 

Lung 


<?/.  auric,  ant. 

■Gl.  nuric.  post. 

■Gl.  I'ugul.  sup. 

Gl.  cervic.  tuperfic.  (fore  part) 
Left  subclavian  vein 
.Gl.  supraclaviculars 


Left  lymphatic  trunk 
Gl.  axill. 


Left  main  bronchus 
Gl.  between  great 
Dcsc.  aorta  vessels 

and  peri- 
'  um 


■Gl.  pleuro  costalea  cardi 
Pericardium 


(Esophagus 
Gl.  lymph,  elerni 
Diaphragm 


Fig.  61. — Bronchial  and  Other  Lymph   Nodes   Mainly  Affected  in  Tuberculosis. 

(Pfaundler  and  Schlossmann.) 


ternal  lymphatics  in  the  neck,  the  groin,  the  axilla  and  elsewhere  is  more 
commonly  followed  by  ulceration  and  the  discharge  of  pus  externally. 

PuLMOXARY  AND  PLEURAL  TUBERCULOSIS. — The  lungs  and  pleura  are 
not  usually  the  site  of  the  primary  lesion  in  the  tuberculosis  of  infants 
and  young  children ;  these  organs  are,  however,  as  a  rule,  involved  second- 
arily in  all  forms  of  severe  tuberculosis.  The  lungs  especially  are  almost 
always  involved  in  well-advanced  tuberculosis,  and  in  the  later  stages 
of  this  disease  are  commonly  the  site  of  widespread  and  destructive  lesions. 
These  lesions  follow  mainly  two  general  types,  a  widespread  dissemina- 
tion throughout  the  lungs  and  pleura  of  gray  miliary  tubercles  accompanied 


380  TTTBERGITLOSIS 

faj  an  intense  congestion  and  hyperemia  ui  the  inrolTed  parts;  or  localized 
patches  of  yellow,  cas^ating  tubercles  which  coalesce,  break  down,  and  dis- 
charge their  purulent  contents  into  the  bronchi  or,  more  rarely,  into  the 
pleura,  thus  forming  small  carities  scattered  throu^bout  the  lungSL  If 
the  pulmonary  proce^  is  a  chronic  one  more  or  less  fibrosis  may  occur 
around  the  diseased  arvas,  resulting  in  encapsulation,  absorption  and  cica- 
tricial contraction.  Tnberculo^  of  the  pleura,  which  is  usually  associated 
with  pnhnonary  tubercukeis.  produces  thickening  of  that  membrane  and 
fibfoas  adhesions  which  may  interfere  with  pulmonary  expansion.  Em- 
pyema may  occur.  The  most  marked  differences  between  the  pulmonary 
ledons  of  infantile  and  adnlt  tuberculosis  are  as  follows:  Infantile  pul- 
monary tuberculosis  is  more  disseminated ;  begins  in  the  middle  and  lower 
lobes  rather  than  in  the  apex;  is  commonly  secondary  to  tuberculosis  of 


Fiw.  &I  — '  ~  ~      f^BOSCELkL    GiukXBi&    AC     RraBi     Ro^Clii. 


the  broDdiial  ._.^^..  ^   .,.^,  and  is  always  accompanied  by  at.  ......  :^    r- 

cnkffiis  of  these  glands. 

Ijnhtbstixai.  TiirBSBCiFiasis. — ^Inteetiiial  tubcxcDl  -^ 
to  mesenteric  lymph-node  tnbeiealo6i&,  or  it  may  V- 
swallowing  of  taberde  bacQUL  Piimaij  intedinal  tuberculous  is  a  rare 
lesian,  aocotding  to  BoTairdj,  who.  combinir^  hk  own  cases  with  those  of 
Holt  and  Mootthmp,  found  only  fiTe  primaij  intestinal  cases  out  of  a 
total  of  369  cases  upon  whom  careful  antiqpraes  had  been  made.  Intestinal 
Ibbmos  UEoalbf  begin  with  tiie  fonnation  of  miliary  tubeardes  in  Peyer's 
pahhes;  they  multiply,  eoakece^  bieak  down,  and  produce  nkers;  these 
nloexs  may  gradually  increaae  in  tsae  until  they  run  together^  forming 
kng^  ulcerated  patches  lying  <^ppo«te  to  the  mesenteric  attachment;  in 
healing  they  may  deatrixe,  causing  moie  oar  kas  eontzacAion  of  the  inlea^ 
tine  in  its  kng  axis. 


PATHOLOGY  381 

TuBEEcrLors  Peeitoxitis. — ^Tuberculous  peritonitis  is  secondary  to 
intestinal  or  peritoneal  lymph-node  tuberculosis;  the  three  conditions  are 
ven"  commonly  associated.  In  peritonitis  the  peritoneal  membrane  is 
studded  with  tubercles,  which  set  up  a  more  or  less  active  inflammation 
that  may  r^ult  in  an  exudation  of  fibrin,  binding  together  the  intestinal 
coils,  the  omentum  and  abdominal  peritoneum,  so  that  the  whole  peritoneal 
carity  may  be  obliterated;  in  other  instances  the  exudation  may  be  sero- 
fibrinous, resulting  in  a  certain  amount  of  agglutination  of  the  intestinal 
coils,  with  a  greater  or  less  quantity  of  serum  in  the  peritoneal  cavity, 
thus  producing  ascites ;  or  tl>e  tubercles  may  adhere,  forming  large  masses 
which  disintegrate,  producing  pockets  of  pus;  these  may  ulcerate  and 
discharge  their  contents  through  the  abdominal  wall  or  into  the  intestine. 
The  writer  once  observed  a  case  of  this  kind  which  ulcerated  through  the 
intestine  and  also  through  the  umbilicus,  forming  a  fecal  fistula,  which 
persisted  for  a  number  of  months  until  the  child's  death. 

Gexeral  Miliary  TuBKRcrLOsis. — General  miliary  tubercnlosis  is 
caused  by  the  discharge  of  tuberculous  pus  into  the  blood  or  lymph  streams. 
The  tubercle  bacilli  are  thus  widely  distributed  throughout  the  body  and 
find  a  lodgment  in  various  organs,  especially  the  lungs,  liver,  spleen,  kid- 
neys and  brain.  Miliary  tubercles  are  soon  widely  disseminated  through 
these  organs  and  later  every  organ  in  the  body  may  be  involved-  Around 
these  tubercles  is  a  small  congested  inflammatory  area,  especially  mailed 
in  tlie  lungs.    The  liver  and  spleen  are  «ilarged. 

BoxE  AXD  Joint  TrBKBcrLOSis. — Bone  and  joint  tuberculosis  is  sec- 
ondary to  tuberculous  foci  elsewhere,  and  the  contagion  is  carried  by  the 
blood  and  lymph  channels  to  these  structures.  This  manifestati<Mi  of  tu- 
bereulosis  in  the  vast  majority  of  cases  begins  in  childhood,  and  is  one 
of  the  common  manifestations  of  this  disease.  The  bones  most  frequently 
affected  are  the  vertebrae,  the  short  bones  of  the  hands  and  feet  and  the 
epiphyseal  portions  of  the  long  bones.  Botch's  table  of  3,8*20  cases  shows 
the  relative  frequency  with  which  the  various  joints  of  the  body  are  at- 
tacked. 

SoUk*s  Table  from  the  ChOdreu's  Hotpital,  Boston. 

Spine     1964 

Hip    1402 

Ankle    300 

Kmee  104 

Wrist    20 

Skoolda-     15 

Elbow   15 

This  form  of  the  disease  b^ins  by  a  deposit  of  tubereles  in  the  can- 
cellous tissue  of  the  bone  near  the  joint,  and  there  result  a  grayish-red 
infiltration  and  inflammation  which  may  be  followed  by  caseation  with  the 
destruction  of  bony  tissue  and  perforation  into  the  joint,  producing  a 
purulent  synovitis.  The  joint  surfaces  are  usually  involved  before  casea- 
tion of  the  bone  takes  place,  and  there  are  produced  a  sero-fibrinous  exuda- 


382  TUBERCULOSIS 

tion  into  the  joint  cavit}^  and  a  deposit  of  tuberculous  granulation  tissue  on 
the  synovial  membrane;  this  granulation  tissue  may  caseate  and  thus  form 
a  purulent  sj^novitis.  It  is  important,  however,  to  remember  that  both 
bone  and  joint  tuberculosis  in  their  earlier  stages  commonly  yield  to 
rational  medical  and  surgical  treatment. 

Symptomatology. — In  studying  the  symptomatology  of  tuberculosis  the 
following  clinical  types  of  this  disease  will  be  considered  in  the  order 
named : 

Tuberculosis  of  lymph  nodes. 

General  miliary  tuberculosis  in  infants. 

General  miliary  tuberculosis  in  older  children. 

Tuberculous  bronchopneumonia  in  young  children. 

Tuberculosis  of  lungs  in  older  children. 

Tuberculous  peritonitis. 

Tuberculosis  of  bones  and  joints. 

(Tuberculous  meningitis  is  studied  with  the  other  forms  of  meningitis.) 

Lymph-Node  Tuberculosis. — ^This  form  of  tuberculosis,  when  it  in- 
volves other  than  the  cervical  lymph  nodes,  is  so  obscure  and  so  commonly 
overlooked  that  it  is  of  the  utmost  importance  that  the  physician  should 
always  keep  in  mind  its  prevalence  and  be  constantly  on  the  lookout  for 
its  signs  and  symptoms.  Many  years  ago  I  expressed  the  opinion,  now  gen- 
erally concurred  in,  that  pronounced  simple  anemia,  occurring  in  young 
children  with  a  history  of  exposure  to  tuberculous  contagion,  was  strongly 
suggestive  of  concealed  lymph-node  tuberculosis,  and  upon  these  condi- 
tions alone  one  was  warranted  in  making  a  tentative  diagnosis  of  tu- 
berculosis and  putting  the  child  upon  the  treatment  for  this  disease.  The 
type  of  anemia  which  occurs  in  tuberculosis  is  a  simple  secondary  anemia 
of  the  chlorotic  type. 

Neurotic  disease  in  children  is  very  frequently  an  indication  of  con- 
cealed lymph-node  tuberculosis.  Over  34  per  cent,  of  the  last  -iOO  tuber- 
culous patients  taken  from  my  dispensary  records  show  well-marked  neu- 
rotic disease,  such  as  chorea,  incontinence  of  urine,  hysteria,  general  nerv- 
ous irritability  and  night  terrors.  A  well-marked  neurosis  therefore  oc- 
curring in  a  child  without  apparent  cause  should  lead  the  physician  to 
search  for  other  symptoms  of  tuberculosis.  Tuberculous  children  of  this 
type  are  commonly  precocious.  The  precocity,  however,  which  is  associated 
with  concealed  tuberculosis,  is  fitful  and  cannot  bo  long  sustained.  In 
the  beginning  of  the  school  year  these  children  may  make  a  brilliant 
showing,  but  they  usually  break  down  in  the  latter  half  of  the  5'ear  with 
well-marked  neurotic  disease  associated  with  anemia  and  general  physical 
weakness.  In  my  dispensary  records  45  per  cent,  of  all  neurotic  children 
are  actively  tuberculous. 

Dyspnea  and  pain  in  the  side  are  in  my  experience  frequently  as- 
sociated with  bronchial  lymph-node  tuberculosis,  even  before  there  is  any 
clear  evidence  of  pulmonary  tuberculosis.    These  symptoms  are  aggravated 

^New  York  Medical  Journal,  August  10,  1895. 


SYMPTOMATOLOGY  383 

by  exercise,  and,  like  the  anemia  and  nervous  symptoms,  are  of  much 
greater  significance  when  they  occur  in  children  with  a  tuberculous  family 
history. 

Respiratory  Symptoms. — Tuberculous  children  catch  cold  readily  and 
often  suffer  from  frequent  attacks  of  snuflies  and  nasal  catarrh.  The  nasal 
discharge  may  be  irritating  and  produce  a  slight  eczema  and  thickening  of 
the  lip,  giving  a  more  or  less  characteristic  expression.  They  may  also 
suffer  from  frequent  attacks  of  bronchitis  even  before  an  active  pulmonary 
tuberculosis  can  be  demonstrated. 

Abnormal  dwarfishness  may  be  an  evidence  of  concealed  tuberculosis. 
By  an  abnormal  dwarf  is  meant  not  only  one  that  is  underweight,  but 
one  that  also  lacks  symmetry  in  development.  The  relation  of  weight  and 
girth  of  chest  is  of  special  importance  in  this  particular.  A  marked  dis- 
proportion between  the  weight  and  height,  when  associated  with  poor  chest 
development  and  a  family  history  of  tuberculosis,  should  prompt  a  careful 
search  for  other  signs  of  bronchial  lymph-node  tuberculosis. 

Progressive  failure  of  health,  loss  of  weight,  or  even  failure  to  gain 
in  weight,  which  in  the  growing  child  is  equivalent  to  loss  of  weight  in 
the  adult,  is  frequently  a  symptom  of  Ij^mph-node  tuberculosis,  and  when 
these  conditions  exist  without  apparent  cause  tuberculosis  should  be  sus- 
pected. 

The  early  appearance  of  and  irregularity  in  the  menstrual  function 
commonly  occurs  in  young  girls  suffering  from  lymph-node  tuberculosis. 
Of  52  girls  who  were  irregular  in  their  menstrual  function,  47  gave  family 
histories  of  tuberculosis  and  5  gave  family  histories  free  from  tuberculosis. 
Of  110  girls  who  were  regular  in  their  menstrual  function,  80  gave  non- 
tuberculous  family  histories,  and  30  gave  family  histories  of  tuberculosis. 
A  family  history  of  tuberculosis  implies  also  the  more  important  fact 
that  there  was  exposure  to  the  tuberculous  contagion. 

If  the  mesenteric  lymph  nodes  be  tuberculous,  and  they  are  rarely 
involved  independently  of  the  bronchial  lymph  nodes,  we  may  have,  to  a 
greater  or  less  degree,  associated  with  the  above  symptoms  dyspepsia  with 
a  tendency  to  chronic  diarrhea.  Obstinate  diarrhea  and  other  gastrointes- 
tinal disturbances  may  occur  in  this  variety  of  tuberculosis  even  before  le- 
sions appear  in  the  intestinal  mucosa;  enlargement  of  the  spleen  is  com- 
monly associated  with  these  symptoms. 

Fever  may  or  may  not  be  present  in  lymph-node  tuberculosis,  but  where 
the  disease  is  at  all  active  a  slight  rise  of  the  temperature  may  usually  be 
discovered,  and  in  aggravated  cases  it  may  rise  regularly  to  103°  or  104° 
F.  some  time  during  the  day.  The  temperature  in  these  cases  produces 
little  or  no  discomfort,  so  that  it  is  not  unusual  for  a  child  with  a  tem- 
perature of  103°  F.  to  protest  that  there  is  nothing  the  matter  with  it. 
Night  sweats  may  be  present,  even  though  there  be  but  a  slight  rise  of 
temperature.  They  are  associated  with  the  anemia,  nervousness  and  mal- 
nutrition of  lymph-node  tuberculosis. 

Friedlander  has  called  attention  to  the  fact  that  a  relative  and  ab- 
26 


384  TUBEECULOSIS 

solute  lympliocyiosis  occurs  in  lympli-node  tuberculosis,  and  when  this 
fact  is  taken  in  connection  with  the  well-established  fact  that  certain 
other  diseases,  such  as  whooping-cough,  also  produce  lymph-node  enlarge- 
ment, and  are  accompanied  by  a  lymphocytosis,  he  suggests  that  this 
sign  may  be  a  valuable  one  in  testifying  to  the  existence  of  an  inflamma- 
tion of  the  lymph  glands  in  cases  where  concealed  tuberculosis  is  suspected. 

Enlargement  of  external  lymph  nodes  in  the  groin,  axilla,  neck  and 
elsewhere  may  be  a  very  important  sign  of  the  existence  of  bronchial  or 
mesenteric  lymph-node  tuberculosis.  The  presence  of  enlarged  external 
lymph  nodes,  which  can  be  easily  seen  and  felt,  if  associated  with  tlie 
symptom  group  previously  described,  is  of  the  greatest  value  in  confirming 
the  diagnosis  of  concealed  tuberculosis,  but  it  must  be  remembered  that 
a  very  advanced  stage  of  bronchial  lymph-node  tuberculosis  may  exist  with 
little  or  no  enlargement  of  external  lymphatics,  and  it  must  also  be 
remembered  that  a  very  extensive  lymph-node  tuberculosis  may  occur  in 
the  cervical  and  other  superficial  lymphatics  with  little  or  no  involvement 
of  the  deep-seated  bronchial  or  mesenteric  lymph  nodes.  The  extent  of 
the  disease,  therefore,  in  external  lymphatics  bears  absolutely  no  rela- 
tionship to  the  extent  of  the  disease  in  deep-seated  lymphatics. 

Skin  tuberculides,  described  by  Hamburger,  may  appear  as  small,  red 
or  brownish  papules,  perhaps  three  or  four  in  number,  scattered  over  the 
body.  They  soon  become  covered  with  a  small  crust,  which  on  removal 
leaves  a  depression.    In  this  crust  tubercle  bacilli  may  be  found. 

Physical  signs  are  rather  unrelial)le  because  of  their  variability.  Great 
enlargement  of  the  bronchial  lymph  nodes  may  exist  without  producing 
physical  signs  which  will  lead  to  their  detection,  but  in  some  cases  the 
physical  signs  are  of  importance.  Percussion  may  elicit  dullness  over 
and  on  either  side  of  the  manubrium  sterni,  and  on  either  side  of  the 
spine  in  the  interscapular  region;  the  dullness  is  more  frequently  found 
on  the  right  side.  Auscultation  is  even  less  reliable  than  percussion. 
Grancher  believes  that  the  harsh  breathing  sounds,  which  are  normal  in 
the  right  apex  of  the  child,  when  greatly  exaggerated,  are  a  sign  of  im- 
portance. The  bronchovesicular  breathing,  with  prolonged  and  harsh  in- 
spiration, which  may  be  heard  in  some  instances  at  the  apex,  is  especially 
important  if  it  occurs  on  the  left  side.  Feeble  breath  sounds  over  the 
whole  of  one  lobe  are  a  sign  of  significance.  A  venous  hum,  as  noted  ])y 
Eustace  Smith,  may  sometimes  be  heard  over  the  manubrium  if  the 
head  of  the  child  is  bent  backward  so  that  the  enlarged  gland  will  com- 
press the  left  innominate  vein  against  the  sternum. 

Palpation  in  mesenteric  lymph-node  tuberculosis  is  of  great  value, 
since  an  enlarged  spleen  may  usually  be  found  and  deep-seated  lymph 
glands,  especially  in  the  region  of  the  appendix,  may  be  made  out.  In 
bronchial  lymph-node  tuberculosis,  however,  palpation  is  of  little  value, 
since  these  glands  cannot  be  felt.  Deep  palpation,  however,  in  the  epi- 
sternal  notch  beneath  the  clavicle,  may  reveal  enlarged  glands,  which  may 
be  associated  with  the  bronchial  chain. 


PLATE  IV. 


\ 


7^ti 


The  von  Pirquet  Tuberculin  Skin  Reactions, 
(From  Haxnill,  Carpenter  and  Cope). 


DIAGNOSIS  385 

Pressure  signs  produced  by  enlarged  lymph  nodes  are  at  times  a  signal 
aid  in  confirming  the  diagnosis  of  bronchial  lymph-node  tuberculosis. 
Hall,  in  a  comprehensive  review  of  the  literature  of  this  subject,  has 
called  special  attention  to  the  value  of  these  signs.  A  severe  paroxysmal 
cough,  resembling  pertussis,  occurring  more  frequently  at  night,  and 
often  associated  with  asthmatic  breathing,  is  a  common  and  very  significant 
symptom.  Pressure  on  the  trachea  may  produce  tracheitis,  inspiratory 
dyspnea  and  cyanosis.  Pressure  on  one  bronchus,  most  commonly  tbe 
right,  may  produce  bronchitis  and  a  diminished  expansion,  and  feeble 
vesicular  breathing  over  that  portion  of  the  lung  to  which  the  bronchus 
leads.  Pressure  on  the  esophagus  may  produce  difficulty  in  deglutition. 
Compression  of  blood  vessels  produces  venous-stasis  with  edema  of  the 
face  and  arms,  and  pressure  on  the  pulmonary  veins  may  produce  con- 
gestion of  the  lungs.  Pressure  on  the  recurrent  laryngeal  nerve  may 
produce  a  hoarse,  harsh  cough  and  even  aphonia. 

Radiographic  examination  of  the  chest  may  reveal  the  existence  of 
enlarged  bronchial  lymph  nodes  and  may  be  of  value  in  confirming  the 
diagnosis.  If  tlie  lung  be  involved  patches  of  consolidation  and  limita- 
tion of  motion  at  base  of  diseased  lung  may  be  seen. 

Tuberculin  reactions  in  recent  years  have  come  to  be  considered  of 
great  value  in  confirming  the  diagnosis  of  concealed  tuberculosis.  They 
are  so  sensitive  that  they  reveal  minute  foci  of  tuberculosis  in  the  latent 
or  inactive  forms  of  this  condition.  The  presence  of  these  reactions 
therefore  does  not  always  mean  an  active  tuberculosis.  The  severity, 
however,  of  the  reaction  and  the  rapidity  with  which  it  occurs  may  be 
of  some  value  in  determining  the  degree  of  activity  of  the  tuberculous 
process.  This  rule  also  has  its  limitations,  since  these  react-ons  fail 
to  appear  in  advanced  cases,  and  their  value  lies  not  in  making  a  dif- 
ferential diagnosis  in  the  acute  and  grave  forms  of  tuberculosis,  but  in 
determining  the  presence  of  tuberculous  foci  in  suspected  cases  of  chronic 
concealed  tuberculosis.  In  these  the  reaction  rarely  fails,  and  a  negative 
result  would  mean  the  absence  of  tuberculosis.  Of  these  tuberculin  re- 
actions, the  Moro  ointment  test  is  the  simplest  of  application  and  is 
sensitive  enough  for  all  practical  purposes.  The  von  Pirquet  scarification 
test  is  also  simple  in  its  technique  and  more  sensitive  in  its  reaction. 
The  conjunctival  test  is  now  rarely  used,  because  it  involves  slight  danger 
to  the  eye.  The  subcutaneous  test  presents  no  advantages  over  the  others, 
is  more  complicated,  and  offers  greater  opportunities  for  infection.  The 
technique  of  these  tests  is  elsewhere  given. 

Diagnosis. — From  the  foregoing  outline  it  is  evident  that  the  diagnosis 
of  concealed  lymph-node  tuberculosis  is  not  only  possible,  but  that  the 
failure  to  make  this  diagnosis  rather  early  in  the  disease  indicates  a  lack 
of  diagnostic  skill  and  knowledge  on  the  part  of  the  attending  physician. 
If  the  fact  is  kept  in  mind  that  it  is  the  most  common  of  all  the  chronic 
diseases  of  childhood,  and  that  a  history  of  possible  exposure  to  the  tu- 
berculous contagion  may  have  occurred  months  and  even  years  before  the 


386  TUBERCULOSIS 

active  symptoms  are  developed,  the  physician  will  then  be  prepared  to 
interpret  the  syndrome  above  outlined.  Anemia,  neurotic  disease,  gen- 
eral malnutrition,  dyspnea  and  pain  in  the  side  on  exercising,  proneness 
to  catch  cold,  frequent  attacks  of  bronchitis,  abnormal  dwarfishness,  pro- 
gressive failure  of  health,  loss  of  weight,  chronic  diarrhea  with  enlarge- 
ment of  the  spleen,  slight  intermittent  fever,  lymphoc}i;osis,  enlargement 
of  external  lymph  nodes,  or  paroxysmal  cough  resembling  pertussis,  oc- 
curring in  a  child  between  the  ages  of  two  and  fifteen,  should  lead  to  a 
tentative  diagnosis  of  concealed  lymph-node  tuberculosis,  which  may  be 
confirmed  or  disproven  by  a  careful  physical  examination,  the  subsequent 
history  of  the  case,  and,  if  necessary,  by  tuberculin  skin  reactions  and 
radiographs. 

Tuberculous  Cervical  Adenitis  (Scrofula). — Tuberculous  cervical 
adenitis  is  almost  as  common  as  tuberculous  bronchial  adenitis;  the  two 
conditions,  however,  present  altogether  distinct  symptom  groups.  The  cer- 
vical lymph  nodes  are  not  in  close  anatomical  connection  with  the  bron- 
chial glands.  The  clinical  facts  that  bronchial  adenitis  is  very  common 
and  cervical  adenitis  very  rare  in  infancy,  and  that  cervical  adenitis  in 
the  older  child  often  occurs  without  evidence  of  bronchial  adenitis,  con- 
firm the  belief  that .  there  is  little  direct  communication  between  these 
two  groups  of  glands.  The  clinical  picture  of  cervical  adenitis  may  be 
quite  independent  of  bronchial  adenitis,  and  the  existence  of  the  two 
symptom  groups  in  the  same  child  means,  in  the  majority  of  instances, 
that  the  child  has  an  independent  infection  of  the  two  groups  of  glands 
rather  than  that  the  infection  has  traveled  from  one  group  to  the  other. 
Tuberculous  cervical  adenitis  is  essentially  a  disease  of  childhood;  it  is 
comparatively  rare  in  the  infant  and  adult.  The  great  majority  of  the 
cases  occur  between  the  third  and  fifteenth  year  of  life. 

The  diagnosis  of  cervical  adenitis  is  a  very  simple  matter.  The  lymph 
nodes  involved  are  readily  palpable  and  the  only  question  which  may  arise 
is  as  to  whether  their  enlargement  is  due  to  an  inflammation  produced  by 
tubercle  bacilli  or  other  microorganisms.  In  tuberculous  cervical  aden- 
itis the  process  is  essentially  a  chronic  one  and  the  glands  are  less  tender. 
When  suppuration  occurs  through  the  skin  the  reparative  processes  are 
slower  and  there  is  more  tendency  to  sinus  formation  and  to  scar  tissue. 
There  are  also  very  frequently  ble])haritis,  phlyctenular  keratitis,  corj'za, 
chronic  nasal  catarrh  and  eczema  of  the  lip  and  face.  A  positive  diagnosis 
of  the  character  of  the  microorganism  producing  the  adenitis  cannot 
always  be  made  without  dissecting  out  the  gland  (which  is  the  best  treat- 
ment in  troublesome  cases),  and  subjecting  it  to  a  microscopical  examina- 
tion or  injecting  it  into  a  guinea-pig.  Because  of  the  fact  that  the  great 
majority  of  the  chronic  cases  are  tuberculous  and  because  of  the  im- 
portance of  instituting  proper  treatment  in  these  cases,  it  is  wise  for  tlie 
physician  to  treat  all  such  cases  as  tuberculous.  When  the  disease  is 
confined  to  the  cervical  glands  the  constitutional  symptoms  are  not  marked ; 
if  pronounced  anemia  and  severe  malnutrition  are  present  the  inference 


DIAGNOSIS  387 

is  that  the  bronchial  or  other  deep-seated  lymph  nodes  are  involved.  Tu- 
berculous cervical  adenitis  usually  manifests  itself  by  enlarged  glands  in  the 
sub-maxillary  region,  varying  in  size  from  a  hazelnut  to  a  walnut;  these 
may  coalesce  and  form  large,  solid  tumor  masses.  Suppuration  may  occur, 
with  the  discharge  through  the  skin  of  curdy,  cheesy  pus,  forming  a  sinus 
which  remains  open  or  is  only  temporarily  closed,  until  the  whole  of  the 
glandular  tissue  involved  is  disintegrated  and  discharged.  Following  and 
accompanying  this  ])rocess  the  skin  may  be  marked  by  large,  rough,  un- 
sightly scars.  Cervical  adenitis  may  be  aggravated,  or  even  caused  by 
disease  of  the  adenoids,  tonsils  and  pharynx. 

General  Miliary  Tuberculosis  in  Infants. — This  is  a  very  in- 
sidious disease,  presenting,  as  a  rule,  only  the  symptoms  of  general  mar- 
asmus. The  infant  commences  to  lose  in  weight  and  strength,  and  is 
anemic.  A  slow  wasting  and  failure  in  health,  without  apparent  cause, 
is  the  dominant  symptom.  This  condition  is  commonly  mistaken  for  some 
disease  on  the  part  of  the  gastrointestinal  canal.  The  infant,  as  a  rule, 
takes  but  little  food  and  has  secondary  digestive  disturbances,  such  as 
regurgitation  of  food,  vomiting  and  diarrhea,  and  the  stools  may  show 
lack  of  digestion  and  assimilation.  After  a  longer  or  shorter  time,  usually 
some  months,  there  is  fever,  which  may  be  constant  or  intermittent,  the 
spleen  and  liver  are  enlarged,  the  digestive  disturbances  are  increased  and 
the  lungs  commence  to  show  evidence  of  bronchitis  and  then  broncho- 
pneumonia. The  terminal  symptoms  are  continuous  fever,  more  or  less 
cough,  rapid  pulse  and  great  prostration.  Death  may  result  from  gen- 
eral exhaustion,  resembling  marasmus,  from  a  terminal  bronchopneumonia 
or  tuberculous  meningitis. 

General  Miliary  Tuberculosis  in  Children  Over  Five  Years  of 
Age. — This  disease  is  always  secondary  to  tuberculous  foci  elsewhere  in 
the  body,  which  have  ulcerated  into  the  blood  or  lymph  streams  and  pro- 
duced the  general  infection.  These  previous  foci  may  be  located  in  the 
lungs  or  the  bones,  but  in  the  vast  majority  of  instances  they  are  in  the 
lymph  nodes,  and  this  is  the  reason  why  this  form  of  tuberculosis  is  nearly 
always  preceded  by  the  symptoms  of  lymph-node  tuberculosis.  This  fact 
cannot  be  too  strongly  insisted  upon.  Following  the  symptoms  of  lymph- 
node  tuberculosis  previously  given,  the  child  becomes  acutely  ill  with  a 
continuous  fever,  marked  by  general  prostration  and  progressive  emaciation, 
causing  a  clinical  picture  closely  resembling  that  of  typhoid  fever  in  the 
adult.  The  two  conditions,  however,  should  not  be  confused.  In  general 
miliary  tuberculosis  the  fever,  although  continuous,  is  not  as  regular  as 
that  of  typhoid,  the  spleen  is  not  so  frequently  enlarged,  digestive  dis- 
turbances are  not,  as  a  rule,  marked,  rose  spots  are  absent,  the  Widal  re- 
action is  negative,  and  as  the  disease  progresses  the  fever  does  not  abate 
at  the  end  of  the  third  or  fourth  week,  but  continues  with  increasing  pros- 
tration, emaciation,  and  cachexia.  A  tuberculous  bronchopneumonia  or 
meningitis  may  terminate  the  clinical  picture. 

Tuberculous  Bronchopneumonia. — This  condition  occurs  most  com- 


388  TUBEECULOSIS 

nionly  in  young  children  between  tlie  ages  of  two  and  five.  It  may  be 
the  terminal  picture  of  the  marantic  type  of  general  miliary  tuberculosis 
in  the  infant.  In  the  child  it  is  much  more  commonly  the  sequel  of  a 
broncliial  lym])h-node  tuberculosis  wbicb  has  existed  for  months  or  even 
years  and  has  been  finally  developed  into  a  tuberculous  bronchopneumonia 
by  an  attack  of  measles,  whooping-cough,  influenza,  or  bronchitis.  The 
temperature  chart  (page  4()0)  indicates  the  course  the  fever  may  take 
and  also  the  increase  in  respiration  as  the  disease  progresses.  Cough, 
dyspnea,  cyanosis  and  great  prostration  are  present.  Tubercle  bacilli  can 
usually  be  demonstrated  in  the  sputum,  which  is  caught  by  wiping  out  the 
pharynx  with  a  piece  of  gauze  during  an  attack  of  coughing.  The  disease 
in  younger  children  may  run  from  two  to  four  weeks  and  is  almost  in- 
variably fatal.  In  children  from  four  to  six  years  of  age  it  may  last  six 
or  eight  weeks,  with  great  variations  in  the  severity  of  the  symptom 
group.  The  apparent  improvement  which  so  often  occurs  in  these  cases 
is  very  misleading,  since  an  acute  exacerbation  of  the  symptoms,  as  a  rule, 
quickly  follows,  and  the  disease  progresses  to  a  fatal  termination.  In 
some  instances,  however,  especially  in  older  children,  one  of  these  in- 
tervals of  apparent  convalescence  may  be  prolonged  into  an  actual  con- 
valescence, and  the  child  is  again  slowly  restored  to  health. 

The  physical  signs  are  those  of  acute  bronchopneumonia  elsewhere 
described.  Rales  of  various  kinds  may  be  heard  over  the  lungs.  Over 
small  areas  crepitant  rales,  diminished  resonance  and  bronchovesicular 
breathing  may  be  found.  The  physical  signs,  however,  may  occur  late  and 
are  often  very  elusive.  The  diagnosis  is  therefore  commonly  made  by  the 
tuberculous  family  history;  previous  or  present  symptouis  of  tuberculosis 
elsewhere  in  the  body;  the  onset  of  the  disease  after  one  of  the  acute 
infections;  the  presence  of  tubercle  bacilli  in  the  sputum,  and  the  symp- 
toms and  signs  of  an  acute  bronchopneumonia,  running,  especially  in 
slightly  older  children,  an  irregular  and  prolonged  course. 

Tuberculosis  of  Lungs  in  Older  Children. — Pulmonary  tubercu- 
losis, in  children  between  the  ages  of  six  and  fifteen,  is  usually  preceded 
by  and  almost  always  associated  with  bronchial  lymph-node  tuberculosis. 
The  symptomatology,  therefore,  of  the  two  conditions  is  inseparably  as- 
sociated. In  the  great  majority  of  instances  there  is  a  longer  or  shorter 
interval  of  time  in  which  the  symptoms  of  bronchial  lymph-node  tuberculo- 
sis are  present  before  the  pulmonary  symptoms  can  be  noted.  In  other  in- 
stances the  infection  of  the  lung  and  the  lymph  nodes  may  be  almost  coin- 
cident, and  in  these  cases  the  two  symptom  groups  may  be  coinbined  from 
the  beginning  of  the  disease.  The  pulmonary  disease,  extending,  as  it  com- 
monly does,  from  the  bronchial  lymph  nodes,  involves  the  middle  ])ortions 
of  the  lungs,  extending  first  to  the  upper  lobes  and  after  a  time  involving 
the  lower  lobes. 

The  symptoms  are  those  of  bronchial  lymph-node  tuberculosis,  asso- 
ciated with  recurring  attacks  of  tuberculous  bronchitis,  or  l)ronchopneu- 
monia.    After  a  time  the  tuberculous  process  localizes  itself  more  definitely 


DIAGNOSIS 


389 


in  the  lungs,  and  tlien  takes  the  form  and  presents  the  symptoms  and  phys- 
ical signs  of  plithisis  in  the  adult.  The  resistance  to  the  progress  of 
this  disease  is  not,  however,  as  great  in  the  child  as  it  is  in  the  adult,  and 
it  therefore  runs  a  more  rapid  course  and  has  a  more  unfavorable  prog- 
nosis. 

The  diagnosis  in  these  cases  is  made  by  the  family  history,  the  pre- 
ceding or  accompanying  symptoms  of  bronchial  lymph-node  tuberculosis, 


Fig.  63. — Pulmonary  Tubebcttlosis  with  Left-sided  Pneumothohax. 

(S.  Lange.) 

the  recurring  attacks  without  apparent  cause  of  bronchitis  and  broncho- 
pneumonia, and  later  the  physical  signs  of  phthisis,  and,  most  important 
of  all,  the  finding  of  tubercle  bacilli  in  the  sputum.  The  sputum  may  be 
obtained  by  irritating  the  epiglottis,  thus  producing  a  cough,  and  as  the 
mucus  is  brought  up  it  is  caught  in  the  back  part  of  the  throat  on  a 
piece  of  gauze.  This  method  of  obtaining  mucus  is,  as  Holt  has  demon- 
strated, very  successful;  tubercle  bacilli  may  be  found  in  the  mucus  thus 
obtained  in  at  least  70  or  80  per  cent,  of  the  cases  of  pulmonary  tuber- 
culosis in  children. 


390 


TUBERCULOSIS 


Tuberculous  Peritonitis. — Tuberculous  peritonitis  occurs  most 
commonly  between  the  fifth  and  the  tenth  year  of  life,  and  is  usually 
secondary  to  mesenteric  lymph-node  tuberculosis;  but  it  may  also  occur 
in  the  later  stages  of  other  forms  of  tuberculosis,  especially  the  general 
miliary  tuberculosis  of  infancy.  The  onset  of  this  condition  is  commonly 
preceded,  for  a  considerable  period  of  time,  by  the  symptoms  of  lymph- 
node  tuberculosis.  The  characteristic  symptoms  of  peritonitis  are  then 
slowly  developed.  There  is  abdominal  tenderness  with  attacks  of  pain, 
vomiting,  and  constipation  or  diarrhea.  The  liver  and  spleen  are  usually 
enlarged.      Abdominal    distention,    with    resistance    and    induration,    are 


NOOC  IN  mONT 

or    SkCRAL 

mOMOHTOMV 


[ITCMNHLIUAC 

(external  chain) 


COMMON  iLi*e 
CXTCRNAL  ILmC 


0»TUI>«TO» 

nehvc 

OBTuniTOII 


CXTtllNAk 


Fig.  64. — Ilio-pelvic  Lymph  Nodes.     (Poirier  and  Charpy.) 

marked,  and  these  signs  may  be  more  or  less  localized,  especially  in  the 
early  stages.  Increase  in  the  abdominal  distention,  with  or  without  ascites, 
may  occur.  Tumor  masses  may  be  felt,  especially  in  the  right  iliac  re- 
gion, about  the  head  of  the  colon,  and  in  the  hypogastric  region  along  the 
thickened  omentum.  Localized  indurations  may  sometimes  be  demon- 
strated by  rectal  examination.  As  the  process  extends  the  abdominal  in- 
duration becomes  general,  the  abdominal  distention  more  marked,  and  the 
emaciation  of  the  arms,  legs,  face,  and  body  more  extreme.  This  pliase  of 
the  disease  may  last  for  months  or  years  with  marked  remissions  and 
exacerbations  in  the  symptom  group,  until  death  or  a  slow  convalescence 
terminates  the  clinical  picture.     The  fever  of  tuberculous  peritonitis  is 


DIAGNOSIS 


391 


irregular  in  type  and  the  fluctuations  in  the  temperature  curve  vary 
with  the  activity  of  the  tuberculous  process.  For  all  practical  purposes 
it  is  safe  to  assume  that  every  chronic  exudative  peritonitis  is  tuberculous, 
notwithstanding  the  fact  that  Henoch  and  other  German  writers  have 
described  a  very  rare  form  of  simple  or  non-tuberculous,  chronic,  exudative 
peritonitis  occurring  in  older  children.  From  a  clinical  standpoint  it 
matters  little  whether  such  a  disease  exists  or  not.  If  it  does,  it  is  ad- 
mittedly a  very  rare  affection  and  its  treatment  is  the  same  as  that  of 
tuberculous  peritonitis. 

While  the  above  clinical  picture  is  the  most  characteristic  and  the 
most  common  one  presented  by  tuberculous  peritonitis,  sharp  variations 
may  occur,  especially  in  acute  cases.  The  sudden  onset,  presenting  the 
symptoms  of  fever,  vomiting,  constipation,  abdominal  distention  and  ten- 
derness in  the  right  iliac  region,  may  closely  resemble  acute  perforative 
appendicitis,  and  the  differential  diagnosis  may  depend  upon  the  previous 
history  or  the  findings  of  an  exploratory  incision.  Less  acute  cases  with 
fever,  diarrhea,  large  spleen,  abdominal  distention,  and  right  iliac  tender- 
ness njay  present  a  picture  somewhat  like  typhoid  fever.  In  these  cases 
the  differential  diagnosis  may  depend  upon  the  absence  of  rose  spots,  a 
negative  Widal  reaction,  and  the  subsequent  course  of  the  disease. 

Tuberculosis  of  Bones  and  Joints. — This  is  a  common  manifesta- 
tion of  tuberculosis  in  children  between  the  ages  of  three  and  fifteen. 
It  presents  itself  in  a  num- 
ber of  distinct  clinical  types, 
of  which  the  most  important 
are:  Pott's  disease,  hip-joint 
and  knee-joint  disease  and 
tuberculous  dactylitis.  All  of 
these  are  surgical  affections, 
but  because  of  the  importance 
of  an  early  diagnosis  their 
characteristic  local  manifest- 
ations are  here  briefly  noted. 

Pott's  disease  (caries  of 
the  spine)  is  a  chronic  tuber- 
culous disease  of  the  spine, 
characterized  by  the  symp- 
toms of  lymph-node  tubercu- 
losis previously  given,  and  by 
a  localized  stiffness,  rigidity, 
pain,  and  tenderness  in  some 
portion  of  the  spinal  column. 
The  pain  is  commonly  referred  to  the  parts  supplied  by  the  spinal  nerves 
irritated  by  the  diseased  bone.  During  this  stage  the  child  assumes  a 
position  in  walking  and  stooping  which  will  relieve  pressure  on  the  verte- 
brae and  keep  the  spinal  column  rigid.    Later  the  spinal  curvature,  which 


Fig.  65. — Lymphatics  of  the  C^cum  and  Appen- 
dix.    (Poirier  and  Charpy.) 


392 


TUBEECULOSIS 


determines  the  diagnosis,  makes  its  appearance.  This  is  usually  a  sharp 
posterior  curvature  producing  a  characteristic  deformity.  It  may  be  dif- 
ferentiated from  rachitic  and  other  spinal  curvatures  by  its  immobility, 
as  demonstrated  in  the  chapter  on  Examination  of  the  Sick  Child.  Com- 
pression myelitis  may  result  when  the  disease  is  in  the  upper  half  of  the 
spine.  If  the  cervical  vertebrae  be  affected,  the  neck  is  held  stiff,  motion  of 
the  head  produces  pain,  usually  of  a  neuralgic  type,  involving  the  occipital 
region  and  sides  of  the  neck.  If  the  dorsal  vertebras  be  involved,  the  body 
of  the  child  is  held  rigid  and  intercostal  neuralgia  and  abdominal  pains  are 
complained  of.  If  the  lumbar  spine  is  diseased  the  neuralgic  pain  extends 
into  tlie  legs  and  may  be  located  in  the  hip  or  knee. 

Hip-joint  disease  is  a  chronic  tuberculous  disease  of  this  joint  which, 
as  a  rule,  is  very  insidious  in  its  onset.     It  is,  however,  usually  preceded 

and  acconij)anied  by  the  symp- 
toms of  lymph-node  tuberculo- 
sis previously  described.  Lame- 
ness, sharp  paroxysmal  i)ain 
often  referred  to  the  knee,  ten- 
derness of  the  joint  and  disin- 
clination to  walk  mark  the 
onset.  Tenderness  may  be  elic- 
ited by  pressing  the  joint  sur- 
faces together,  and  as  this  in- 
creases the  lameness  becomes 
more  marked.  Eeflex  muscu- 
lar rigidity  produces  a  stiffness 
of  the  joint  or  a  limitation  of 
its  motions.  The  muscles  of 
tlie  thigh  and  calf  show  marked 
atrophy,  and  if  the  child  is 
placed  in  an  upright  position 
the  flattening  in  the  gluteal 
fold  of  the  affected  hip  and 
lack  of  symmetry  of  the  two 
sides  are  very  characteristic. 
As  the  disease  progresses  to 
the  second  stage  the  hi]i  joint 
becomes  fixed,  the  thigh  flexed 
and  somewhat  adducted,  due  to  contraction  of  the  ilio-psoas  muscle  from 
muscular  spasm.  The  cordlike  contracture  of  this  muscle  is  an  important 
diagnostic  sign.  Lordosis  and  tilting  of  the  pelvis  occur.  In  the  third 
stage  the  thigh  is  rotated  inward,  adducted,  and  the  deformity  of  the  hip 
becomes  much  greater.  The  leg  is  drawn  up  by  muscular  action,  is  several 
inches  shorter  than  normal,  and,  while  the  hip  may  be  much  swollen,  the 
lower  portion  of  the  thigh  and  leg  are  wasted.  An  abscess  may  form  and 
',)oint  in  Scarpa's  triangle  in  the  gluteal  region  or  above  Poupart's  ligament. 


Fig.  66. — Tuberculosis  of  Spine. 
disease.) 


(Pott's 


PROPHYLAXIS  393 

Knee-joint  tuberculosis  is  characterized  by  pain  and  a  chronic  "white 
swelling"  of  the  joint.  The  Joint  motions  are  limited  and  the  swelling  is 
commonly  boggy  or  gelatinous  in  character. 

Tuberculous  dactylitis  occurs  in  the  phalanges  of  the  hands  and  feet. 
The  swelling  extends  from  joint  to  joint,  is  essentially  chronic,  is  pyriform 
in  shape  and  boggy  in  character. 

An  X-ray  picture  may  be  of  great  value  in  confirming  the  diagnosis 
of  bone  and  joint  tuberculosis. 

Prophylaxis. — In  April,  1896,  I  was  asked  to  take  charge  of  a  tubercu- 
lous patient  for  the  purpose  of  protecting  her  unborn  child  from  tubercu- 
losis. On  the  mother's  side  there  was  a  family  history  of  tuberculosis.  The 
father  was  sturdy  and  his  family  history  had  no  tuberculous  taint.  The 
mother  was  confined  to  her  bed  with  an  advanced  stage  of  pulmonary  and 
laryngeal  tuberculosis. 

The  sick  room,  divested  of  all  unnecessary  hangings  and  carpets, 
was  thoroughly  cleansed;  this  was  repeated  at  short  intervals  during  the 
mother's  long  illness.  A  trained  nurse  was  installed  and  instructed  in 
the  methods  of  destroying  tubercle  bacilli.  The  patient  coughed  into 
gauze  napkins  and  the  sputum  was  at  once  destroyed  by  fire.  It  was 
with  the  greatest  difficulty  that  the  mother  was  kept  alive  by  hypodermic 
medication  and  such  food  and  alcohol  as  she  was  able  to  take,  until  the 
baby  was  born  in  September,  five  months  later.  Previous  to  the  birth  of 
the  child,  a  large  and  well-aired  room  on  the  same  floor  of  the  house  as 
the  mother's  bedroom  was  selected.  Everything  was  removed  from  this 
room,  the  paper  w^as  taken  from  the  wall,  the  room  repapered,  the  wood- 
work and  floors  scrubbed  and  washed  down  with  a  solution  of  bichlorid  of 
mercury,  and  new  furnishings  supplied.  On  the  birth  of  the  child  he 
was  removed  immediately  to  this  room  and  placed  in  charge  of  a  wet 
nurse.  The  mother  lived  nine  weeks  after  the  birth  of  her  child  and 
during  this  time,  in  deference  to  her  self-sacriflcing  spirit,  the  infant 
was  carried  into  the  sick  room  once  a  day,  remaining  there  for  a  few 
minutes  only.  But  the  mother,  a  very  intelligent  woman,  did  not  nurse 
or  fondle  her  child  during  this  time.  Before  each  daily  visit  of  the  infant 
to  its  mother's  room,  the  windows  of  the  sick  room  were  opened  and  the 
room  aired.  On  the  death  of  the  mother  the  whole  house  was  carefully 
fumigated  and  cleansed.  Every  room  was  repapered,  and  the  floors  and 
woodwork  scrubbed  and  washed  down  with  bichlorid  of  mercury.  The 
furniture  was  cleansed,  the  carpets  and  hangings  all  over  the  house  were 
replaced  by  new  ones  and  the  bedding  of  the  sick  room  was  destroyed  by 
fire.  The  infant,  which  at  birth  was  very  frail  and  malnourished,  com- 
menced to  thrive  and  gradually  grew  stronger,  so  that  when  he  was  a 
few  weeks  of  age  he  commenced  his  daily  outings.  From  that  time  he 
was  kept  in  the  open  air  as  much  as  possible,  slept  in  a  well-ventilated 
room  and,  when  nine  months  of  age,  was  gradually  weaned  and  placed 
upon  cow's  milk.  During  the  next  five  years  of  the  child's  life  the  fresh- 
air  treatment  was  continued,  and  he  was  carefully  fed  within  the  range  of 


394  TUBEECULOSIS 

his  digestive  capacity;  milk,  eggs,  meat,  and  cereals  were  utilized  as 
much  as  possible  in  building  up  his  nutrition;  under  this  regime  he  con- 
tinued to  thrive  in  a  normal  manner.  During  this  period  he  was  carefully 
protected  from  all  contagious  diseases,  especially  tuberculosis,  measles,  in- 
fluenza and  pertussis.  Between  seven  and  nine  years  of  age,  however,  he 
went  safely  through  measles  and  pertussis,  which  he  contracted  at  school. 
The  boy  is  now  seventeen  years  of  age,  is  well  developed  physically,  and  is 
spending  his  winters  in  an  Eastern  boarding  school  and  his  summers  in 
the  open,  camping  out.  x\t  the  time  of  the  birth  of  this  boy  he  had  one 
sister,  three  and  a  half  years  of  age,  who  lived  in  the  same  house  and 
who  was  as  carefully  protected  from  tuberculosis  during  this  time  as  was 
her  younger  brother.     She  is  to-day  a  normal,  sturdy  girl  of  twenty. 

This  narrative  portrays  the  underlying  principles  which  should  be 
adopted  in  the  prophylactic  treatment  of  tuberculosis,  and  illustrates  what 
can  be  accomplished  by  the  careful  carrying  out  of  these  principles,  without 
removing  the  child  from  its  immediate  tuberculous  surroundings.  It  also 
most  forcibly  illustrates  the  axiomatic  fact  that  the  prevention  of  con- 
tagion in  family  tuberculosis  is  largely  a  question  of  money.  The  father 
in  this  instance  had  ample  means,  was  a  man  of  intelligence,  and  urged 
that  no  expense  be  spared  in  the  protection  of  his  children,  and  the  re- 
sult was  a  satisfactory  one. 

The  prevention  of  tuberculosis,  however,  among  the  poor  is  altogether 
a  different  problem,  and  one  that  cannot  be,  or  at  least  has  not  as  yet  been, 
satisfactorily  solved.  In  dealing  with  an  individual  case  the  physician 
must  therefore,  within  his  limitations,  carry  out  the  following  principles. 
Tubercle  bacilli,  from  whatever  source  they  may  possibly  come,  must  be 
destroyed  by  germicides  or  fire  so  as  to  prevent  the  contamination  of  the 
immediate  surroundings  of  the  patient.  The  sputum  must  be  carefully 
collected  and  destroyed,  and  the  room  in  which  the  tuberculous  patient 
lives  must  be  cleansed  and  disinfected  as  often  as  possible.  Children 
should  not  be  allowed  to  come  in  close  contact  with  tuberculous  individuals, 
as  there  is  not  only  danger  from  the  dried  tubercle  bacilli  scattered  about 
the  room,  but  also  from  the  tuberculous  spray  which  is  projected,  by 
coughing,  several  feet  into  the  surrounding  atmosphere.  This  rule  ap- 
plies not  only  to  the  social  and  home  life  of  the  child,  but  also  to  its 
school  life.  Systematic  school  inspection  is  of  importance  in  preventino- 
the  spread  of  tuberculosis  and  other  infectious  diseases.  Kissing  and 
fondling  of  children  by  tuberculous  patients  should  be  absolutely  pro- 
hibited. Cow's  milk  should  be  obtained  from  a  non-tuberculous  herd  of 
cattle,  and  its  subsequent  contamination  by  tubercle  bacilli  most  carefully 
avoided,  and  where  these  conditions  cannot  be  satisfactorily  carried  out 
the  milk  should  be  pasteurized  for  forty  minutes  at  a  temperature  of 
140°  F. 

An  infant  should  under  no  conditions  be  allowed  to  nurse  a  tubercu- 
lous mother  or  wet-nurse,  because  such  milk  is  not  only  likely  to  be  in- 
nutritious,  but  because  the  child  comes  in  such  close  contact  with  the 


TREATMENT  395 

tuberculous  nurse  that  there  is  great  danger  of  its  contracting  the  dis- 
ease. Under  ordinary  conditions  it  is  far  safer  to  separate  the  young 
child  from  its  tuberculous  surroundings  for  at  least  a  portion  of  the 
time,  in  this  way  diminishing  the  danger  of  contagion  and  placing  the 
child  in  surroundings  where  it  can  get  purer  air  and  more  sunshine,  look- 
ing to  its  physical  upbuilding  and  increased  resistance  to  the  tuberculous 
contagion;  where  this  cannot  be  done  it  is  advisable  to  remove  the  in- 
fected member  of  the  family  and  clean  up  the  surroundings. 

Children  with  a  tuberculous  family  history,  which,  as  a  rule,  im- 
plies that  they  have  had  opportunities  to  contract  the  contagion,  should 
be  carefully  guarded  throughout  their  whole  childhood  from  tuberculosis, 
measles,  pertussis  and  infliienza,  the  last  three  named  diseases  being 
especially  potent  factors  in  preparing  the  soil  and  opening  the  gateways 
for  tuberculous  contagion,  and  also  in  developing  a  latent  into  an  active 
tuberculosis.  Children  of  this  class  should,  if  possible,  live  in  the 
country  and  spend  their  winters  in  some  warm,  dry  climate,  which  will 
enable  them  to  live  an  out-of-door  life,  but  wherever  they  are  located,  in 
the  city  or  in  the  country,  under  suitable  or  unsuitable  climatic  con- 
ditions, they  should  live  in  the  open  air  and  sleep  in  well-ventilated  rooms, 
or  out  of  doors,  when  possible.  During  all  of  this  time  they  should  have 
great  care  given  them  in  the  selection  of  their  food.  Eating  good,  nu- 
tritious food  at  proper  intervals  and  indulging  in  outdoor  sports  will 
do  much  to  develop  a  physique  which  gives  the  child  an  increased  re- 
sistance to  the  tuberculous  contagion.  Because  of  the  prevalence  of  tu- 
berculosis all  children,  whether  coming  from  tuberculous  stock  or  not, 
should,  to  protect  them  not  only  from  this,  but  from  other  contagious 
diseases,  have  careful  attention  devoted  to  diseases  of  the  nose,  pharynx, 
tonsils  and  adenoids.  The  eradication  of  diseased  tissues  in  these  loca- 
tions will  at  least  partially  close  the  most  common  gateway,  not  only  to 
tuberculosis,  but  to  a  number  of  other  contagious  diseases. 

Treatment. — General  Treatment. — As  previously  noted,  lymph-node 
tuberculosis  is  more  common  than  all  the  other  contagious  diseases  of 
childhood.  The  fact  therefore  that  it  is  so  prevalent  and  that  it  is  so 
insidious  should  make  the  physician  very  quick  to  suspect  its  presence, 
and  to  institute  proper  treatment  long  before  the  serious  types  of  tliis 
disease  announce  themselves  in  a  form  that  places  the  child  beyond  the 
reach  of  curative  treatment,  and  also  before  such  diseases  as  measles, 
pertussis,  influenza,  and  bronchopneumonia  make  the  diagnosis  by  de- 
veloping a  curative  into  a  much  more  serious  form  of  tuberculosis.  The 
principles  which  underlie  the  successful  treatment  of  active  tuberculosis 
in  children  are  very  much  the  same  as  those  above  outlined  under  Prophy- 
lactic Treatment.  The  child,  if  of  school  age,  must  stop  school  and  live 
an  outdoor  life  in  a  moderately  bracing  climate  that  will  give  him  the 
purest  air,  the  most  sunshine,  and  the  most  equable  temperature.  These 
axionuitic  facts  mean  that  the  individual  child,  within  the  limitations  of 
the  circumstances  surrounding  it,  should  have  as  much  country  life  as 


396  TUBERCULOSIS 

possible  either  at  home  or  in  a  more  suitable  climate.  Southern  Califor- 
nia and  portions  of  South  Carolina,  Georgia,  Florida,  Texas,  and  New 
Mexico  offer  suitable  winter  climates,  while  the  Adirondacks  and  Colorado 
offer  satisfactory  summer  climates.  The  advantages  of  sanatoria  in  the 
treatment  of  tuberculosis  in  childhood  are  nothing  like  as  great  as  they  are 
in  the  adult.  The  sanatorium  treatment  in  children  would  be  of  advantage 
to  those  who  have  not  the  means  to  take  proper  care  of  themselves  at 
home  or  to  take  advantage  of  a  change  of  climate  when  the  conditions 
demand  it;  such  sanatoria  would  have  to  be  furnished  by  the  state.  The 
facilities  for  sanatorium  treatment  among  the  poor  are  very  limited;  the 
most  that  can  be  done  for  these  children  at  the  present  time  is  to  send 
them  for  short  stays  to  "Fresh  Air  Farms,"  and  other  like  excursions 
into  the  country.  The  tuberculosis  dispensaries  as  now  organized  in 
large  cities  are  of  great  value  in  the  treatment  and  prevention  of  tu- 
berculosis among  the  poor.  These  dispensaries,  with  their  doctors  and 
visiting  nurses,  keep  in  touch  with  their  patients  and,  by  cooperation 
with  "fresh  air"  and  other  organized  charities,  are  able,  in  a  limited  way, 
to  give  them  better  air  and  better  food. 

While  the  climatic  treatment  of  tuberculous  children  is  in  selected 
cases  of  the  greatest  possible  value,  yet  the  fact  remains  that  the  vast 
majority  of  tuberculous  children  must  be  treated  at  home,  if  not  for  the 
whole,  at  least  the  greater  portion  of  the  year.  It  is  encouraging  therefore 
to  note  that  the  home  treatment  of  tuberculous  children  among  the  well- 
to-do  and  middle  classes  is  almost,  or  quite,  as  successful  as  any  climatic 
or  sanatorium  treatment  could  be.  The  home  offers  many  advantages,  es- 
pecially in  the  way  of  proper  food,  quiet  surroundings,  well- ventilated  or 
open-air  sleeping  apartments,  and  protection  from  other  contagions.  It 
may  require  that  the  family  remove  to  the  suburbs  of  the  city  in  which 
they  live  and  there  give  the  child  an  out-door  life  with  proper  food  and 
wholesome  surroundings.  The  fresh-air  treatment  of  tuberculosis  is,  as  a 
rule,  more  satisfactorily  carried  out  in  the  home  than  it  is  at  a  summer 
or  winter  resort  to  which  the  family  have  flown  with  inadequate  means 
to  provide  for  themselves  and  their  sick  child  the  proper  sanitary  sur- 
roundings. If  the  tuberculous  process  is  active  enough  to  produce  fever, 
the  home  is  by  far  the  most  satisfactory  place  for  the  treatment  of  such 
cases.  These  children  require  rest  in  bed  for  all  or  at  least  a  greater 
portion  of  the  day,  and  they  must  have  what  all  tuberculous  patients 
demand,  fresh  air,  sunshine,  and  proper  food.  These  conditions  can  best 
be  complied  with  at  home,  except  among  the  very  poor,  and  they  can 
be  cared  for  in  the  fresh-air  wards  of  our  public  hospitals. 

Fresh-air  Treatment. — In  properly  carrying  out  this  treatment  the 
child  should  be  required  to  sleep  out  of  doors;  this  can  be  accomplished 
in  the  great  majority  of  cases.  My  experience  with  the  out-door  treat- 
ment of  tuberculosis,  and  many  other  diseases,  has  been  in  and  around 
Cincinnati,  Ohio;  the  winter  climate  here  is  like  that  of  New  York, 
Philadelphia  and   St.   Louis,  cold,  damp,  and  unwholesome.     From  the 


TKEATMEXT  397 

latter  part  of  December  to  the  latter  part  of  March  the  climate  is  most 
variable,  rains,  snows,  high  winds,  zero  temperature,  and  thawing  weather 
may  follow  each  other  in  rapid  succession,  and  influenza,  and  catarrhal 
diseases  prevail.  Yet  even  in  this  climate  very  remarkable  curative  re- 
sults can  bo  obtained  from  sleeping  out  of  doors  throughout  the  winter 
months.  I  have  found  that  children,  both  sick  and  well,  when  they  have 
once  been  trained  to  it,  prefer  porches  and  verandas  to  indoor  sleeping 
apartments.  During  the  extreme  cold  weather  of  winter,  special  sleeping 
garments  and  extra  bed  clothing  are  necessary,  and  the  porch  may  be 
supplied  with  canvas  drop  curtains,  one  or  more  of  which  may  be  let 
down  on  stormy  nights.  Sleeping  in  rooms  with  wide  open  windows, 
while  not  as  good,  is  a  fair  substitute  for  out-door  sleeping  apartments. 
The  value  of  this  fresh-air  treatment  for  both  sick  and  well  children  can 
scarcely  be  overestimated.  After  spending  the  best  part  of  the  day  breath- 
ing the  impure  and  germ-laden  air  of  the  schoolroom,  it  is  a  crime  to  shut 
children  up  in  close  and  ill-ventilated  sleeping  apartments  for  the  night. 
These  are  the  conditions  that  aggravate  tuberculosis  and  promote  the 
spread  of  influenza  and  other  contagions.  Sleeping  out  of  doors  the  year 
around  is  the  most  potent  single  measure  we  have  for  the  cure  of  tu- 
berculosis, and  it  is  much  more  effective  in  the  chronic  glandular  tuber- 
culosis of  childhood  than  it  is  at  any  other  age  or  in  any  other  form. 
In  fact,  this  form  of  tuberculosis,  between  the  ages  of  four  and  ten,  yields 
almost  specifically  to  the  fresh-air  treatment. 

Dietetic  Treatment. — In  children  this  is  almost  as  important  as  the 
fresh-air  treatment  and  can  be  carried  out  nowhere  so  well  as  at  home. 
The  nutritional  problems  of  the  tuberculous  child  must  be  carefully  studied 
by  the  physician,  and  a  diet  containing  food  easily  within  the  range  of 
his  digestive  capacity  should  be  carefully  prescribed.  Proper  food  at  reg- 
ular intervals  must  be  given  over  a  long  period  of  time.  In  the  average 
child  this  food  should  be  made  up  largely  of  milk,  eggs,  meat,  and  cereals, 
but  the  age  and  digestive  capacity  of  the  individual  child  must  guide  the 
physician  in  his  selection  of  the  diet.  One  fact  should  be  firmly  im- 
pressed upon  the  physician's  mind,  and  that  is  that  he  can  never  cure  a 
case  of  tuberculosis  unless  he  is  able  to  successfully  solve  the  nutritional 
problems  of  the  child.  It  is  only  the  well-nourished  child,  with  good 
digestion,  continuously  fed  upon  proper  food,  that  finally  gets  well  of 
tuberculosis.  The  younger  the  child  the  more  important  is  the  dietetic 
treatment  and  the  less  probable  that  a  change  of  climate  will  be  of 
greater  curative  value  than  careful  dietetic  home  treatment.  It  is,  of 
course,  possible  for  the  well-to-do  to  combine  home  life  with  change  of 
climate.  When  this  is  possible  we  have  the  ideal  conditions  for  the  proper 
treatment  of  tuberculosis  in  children.  It  has  not  been  my  purpose  here 
to  undervalue  the  great  curative  power  of  a  suitable  climate  in  the 
cure  of  tuberculosis  in  children,  but  only  to  call  attention  to  the  fact  that 
so  much  stress  has  been  laid  upon  this  factor  that  many  children  suffer- 
ing from  tuberculosis,  are  carried  away  from  good  homes  to  a  boarding- 


398  TUBERCULOSIS 

lioiise  or  hotel  life  that  does  not  offer  as  favorable  opportunities  for  the 
treatment  of  this  disease  as  they  left  behind  them.  The  successful  treat- 
ment of  tuberculous  children  must  for  the  most  part  be  carried  out  at 
home,  and  the  climatic  treatment  is  only  a  valuable  adjunct,  which  is  to 
be  prescribed  to  meet  the  needs  of  the  individual  child. 

Eest  and  Exercise. — Eest  and  exercise  should  be  as  carefully  pre- 
scribed to  meet  the  needs  of  the  patient  as  any  of  the  other  measures 
adopted  for  the  cure  of  tuberculosis.  All  acute  exacerbations  of  this 
disease,  especially  those  associated  with  fever,  loss  of  weight,  and  a  weak 
and  rapid  pulse,  should  be  treated  by  rest  rather  than  exercise.  Whether 
the  child  shall  rest  in  bed,  with  wide-open  windows,  or  on  a  lounge,  or 
in  a  comfortable  chair,  will  depend  upon  the  severity  of  the  acute  symp- 
toms and  upon  its  individual  idiosyncrasies,  the  object  being  to  give  the 
child  bodily  rest  without  producing  nervous  irritability  by  the  confine- 
ment which  rest  imposes.  As  it  convalesces  from  acute  symptoms,  mod- 
erate exercise  out  of  doors,  under  careful  supervision,  should  be  prescribed. 
In  the  more  chronic  forms  of  the  disease,  where  the  acute  symptoms  are 
in  abeyance,  more  active  exercise  is  of  value.  But  at  all  times  one  should 
be  careful  to  note  that  the  prescribed  exercise  should  not  be  of  such  a 
character  or  so  long  continued  that  it  will  produce  undue  fatigue  or 
be  followed  by  a  rise  of  temperature.  With  these  restrictions,  out-of-door 
exercise  is  a  most  valuable  adjunct  in  the  treatment  of  tuberculosis  in 
children.  Swedish  movements,  general  massage,  mild  gymnastics,  and 
respiratory  exercises  are  of  value  in  individual  cases,  especially  where  there 
are  poor  chest  development  and  general  malnutrition,  combined  with  rapid 
heart  action  and  rise  of-  temperature  on  moderate  out-door  exercise. 

Medical  Treatment. — While  fresh  air  and  proper  diet  are  recog- 
nized as  the  all-important  measures  in  the  treatment  of  tuberculosis  in 
childhood,  it  is  my  belief  that  the  administration  of  drugs  is  a  very 
important  adjunct  to  this  treatment  and  that  in  recent  years  too  little  at- 
tention has  been  paid  to  this  phase  of  the  subject.  In  administering 
drugs,  it  is  an  axiomatic  fact  that  all  medicines  which  upset  the  di- 
gestion, interfere  with  the  appetite,  or  disturb  the  normal  nutritional 
processes  of  the  infant  and  child,  do  more  harm  than  good,  and  sliould 
therefore  be  very  carefully  avoided.  Creosote,  guaiacol,  and  their  de- 
rivatives have  long  been  recognized  as  valuable  remedies  in  the  treatment 
of  tuberculosis.  But  these  remedies,  when  given  by  the  mouth  to  children, 
commonly  do  more  harm  than  good.  For  this  reason  I  have  for  the 
last  fourteen  years  preferred  to  administer  them  by  inunction.^  Guaiacol 
is  especially  suitable  to  this  form  of  administration.  The  prescription 
introduced  by  me,  many  years  ago,  is  as  follows : 

Ji     Guaiacol    3  i 

Lanolin   (anhydrous)    5  j 

Sig.  Level  teaspoonful  externally  once  or  twice  a  day. 

The  technique  of  the  application  of  this  ointment  is  as  follows:     The 
^  American  Journal  of  the  Medical  Sciences,  January,  1909. 


TREATMENT  399 

skin  of  the  chest  and  abdomen  are  carefully  washed  with  soap  and  warm 
water,  aijd,  after  thoroughly  drying  the  surface,  one  drachm  of  the  oint- 
ment is  carefully  and  gently  rubbed  into  the  skin  of  the  chest  and  upper 
part  of  the  abdomen;  the  inunction  should  be  continued  from  five  to  ten 
minutes.  In  this  way  the  guaiacol  can  be  introduced  into  the  lymph 
and  blood  channels  of  the  child  and,  passing  through  these  circulating 
media,  can  be  found  in  the  urine  within  two  hours  after  tlie  application. 
Guaiacol  administered  in  this  way  is  perhaps  the  best  lymphatic  antiseptic 
which  we  possess,  and  there  can  be  no  doubt  but  that  when  it  is  thus 
administered  we  get  the  full  medicinal  and  constitutional  effects  of  the 
drug  without  disturbing  the  digestive  organs  and  without  interfering 
with  the  healthful  nutritional  processes  of  the  body.  I  have  arrived  at 
these  conclusions  from  the  use  of  this  drug,  over  a  long  period  of  time, 
in  a  very  large  number  of  cases.  In  infancy  the  ordinary  dose  is  one 
drachm  of  the  ointment  applied  once  a  day;  in  childhood  the  same  dose 
twice  a  day.  My  clinical  experience  with  the  use  of  guaiacol  in  this  way 
leads  me  to  the  belief  that  it  is  of  decided  value  as  a  therapeutic  measure, 
not  only  in  all  the  chronic  forms  of  this  disease  but  also  in  the  acute 
processes  for  controlling  the  fever,  cough  and  nervous  symptoms. 

Cod-liver  oil  is  one  of  the  most  valuable  remedies  we  possess,  especially 
in  the  treatment  of  the  chronic  forms  of  tuberculosis  in  children.  It  is 
also  of  great  value  as  a  prophylactic  measure  in  the  latent  tuberculosis  of 
childhood,  and  in  improving  the  nutrition  and  increasing  the  powers  of 
resistance  in  delicate  children  having  a  family  history  of  tuberculosis. 
Cod-liver  oil  gives  the  best  results  when  administered  after  meals,  either 
in  the  form  of  pure  oil  or  combined  with  one  of  the  malt  extracts,  or 
made  into  a  palatable  emulsion ;  my  preference  is  for  the  combination  with 
one  of  the  malt  extracts.  The  individual  idiosyncrasies  of  the  patient, 
however,  must  decide  not  only  the  form  in  which  the  oil  is  to  be  given 
but  also  as  to  whether  it  should  be  given  at  all.  Fresh  syrup  of  the  iodid 
of  iron,  combined  with  some  palatable  vehicle,  such  as  a  liquid  diastase 
or  essence  of  pepsin,  is  a  very  valuable  remedy,  especially  in  the  chronic 
forms  of  lymph-node  tuberculosis  in  older  children.  There  is  no  doubt  as 
to  the  value  of  iodin  in  this  form  of  tuberculosis,  and,  if  desirable,  it  may 
be  administered  by  inunction,  combining  5  or  10  per  cent,  of  iodin  with 
anhydrous  lanolin.  Inunctions  of  this  ointment  are  of  special  value  in 
superficial  lymph-node  tuberculosis  of  the  cervical  lymphatics;  when  ap- 
plied in  this  way  the  remedy  is  quickly  absorbed  and  appears  in  the  urine 
within  two  hours  after  it  is  given.  In  the  administration,  however,  of 
iodin  in  the  chronic  tuberculosis  of  childhood,  I  much  prefer  one  of  the 
following  prescriptions : 

JJ     lodonucleoids      grs.  xl                  B     Comp.   syrup  hypophos...      f  i 

Ferri  carb.  sach 3  iss                            Syrupi  hydriodic  acidi ....     |   i 

M.     ft.  chart  No.  30  Liquid  diastase   5  ii 

Sig.  One   powder  in  half  teaspoonful  of  Teaspoonful      after      eating.        For 

malt  ext.  after  meals.  For  a  child               child  6  years  of  age. 
6  years  of  age. 
27 


400  TUBERCULOSIS 

It  is  mj  belief  from  a  clinical  experience  extending  over  a  numl)er  of 
years  that  these  two  prescriptions  are  of  signal  value  in  the  treatment  of 
the  chronic  tuberculosis  of  childhood.  Their  continuous  use  influences 
favorably  the  nutritional  conditions  of  the  child  and  slowly  and  gradually 
improves  the  anemia,  which  is  such  a  constant  symptom. 

Arsenic  given  in  the  form  of  Fowler's  solution  combined  with  a  suit- 
able vehicle  is  a  remedy  that  exercises  a  favorable  influence  on  nutritional 
processes  and  improves  the  blood  state  of  older  children  suffering  from 
chronic  forms  of  tuberculosis. 

Tuberculin  is  of  comparatively  little  value  in  the  treatment  of  tuber- 
culosis in  young  children.  In  older  children,  however,  it  may  be  used  in 
subacute  or  chronic  cases  in  the  same  manner  and  with  the  same  favor- 
able results  as  in  the  adult.  In  cases  that  are  progressing  favorably  the 
injection  of  minute  doses  of  tuberculin  at  considerable  intervals  lights  up 
the  latent  foci  and  brings  about  a  more  rapid  and  more  complete  eradica- 
tion of  this  disease.     (See  Vaccine  Therapy.) 

Cough. — The  paroxysmal  cough  which  is  so  common  in  the  chronic  tu- 
berculosis of  childhood  should  be  treated  by  the  bromides  and  tincture  of 
belladonna  combined  with  some  suitable  vehicle,  such  as  the  essence  of 
pepsin,  great  care  being  taken  not  to  disturb  the  child's  digestive  organs 
with  these  remedies.  Chloral  is  also  a  remedy  of  value  when  the  cough 
is  unusually  troublesome,  but  opiates  are  very  rarely  indicated.  It  is  best 
to  use  these  cough  sedatives  only  at  night,  and  in  those  cases  only  in  which 
there  is  such  an  acute  exacerbation  of  this  symptom  that  the  child's  rest 
is  very  much  disturbed. 

Diarrhea,  especially  in  older  children,  is  best  combated  by  small  doses 
of  oxid  of  zinc,  one-fourth  to  one-half  grain,  combined  with  subnitrate 
of  bismuth.  Zinc  oxid  is  a  remedy  of  great  value  in  controlling  the 
diarrhea  in  intestinal  and  mesenteric  lymph-node  tuberculosis. 

Fever. — While  rest  is  the  most  important  agent  in  the  control  of 
fever,  medical  remedies  may  be  indicated.  Among  these  may  be  mentioned 
guaiacol  by  inunction,  phenacetin,  aspirin,  and  pyramidon.- 

The  treatment  of  tuberculosis  as  above  outlined  applies  to  all  forms 
of  tuberculosis  in  children  which  offer  the  hope  of  a  favorable  termina- 
tion. It  is,  however,  especially  applicable  to  the  great  group  of  cases 
classed  under  chronic  lymph-node  and  chronic  bone  and  joint  tubercu- 
losis. It  remains,  therefore,  only  to  call  attention  to  the  additional  treat- 
ment which  may  be  necessary  in  the  special  types  of  tuberculosis  occurring 
at  different  ages  in  the  life  of  the  child. 

Cervical  Lymph-xode  Tuberculosis. — Because  of  the  fact  that  this 
form  is  not  infrequently  the  only  tuberculosis  in  the  body  and  because 
disease  of  these  glands  does  not  ordinarily  imply  bronchial  lymph-node 
tuberculosis,  and  especially  because  the  diseased  tissues  are  so  accessible 
to  the  surgeon's  knife,  it  is  to  be  considered,  especially  in  aggravated 
cases,  a  disease  in  which  surgical  interference  offers  the  quickest  and 
safest  means  of  recovery.     Tuberculous  cervical  lymph  nodes  which  do 


TKEATMENT  *  401 

not  yield  to  the  general  treatment  for  this  condition  should  therefore  be 
removed  by  careful  dissection.  There  is  some  danger  that  this  operation, 
if  carelessly  performed,  may  inoculate  neighboring  tissues  and  may  even 
produce  a  general  tuberculosis.  Following  the  removal  of  the  glands  the 
long-continued  application  of  the  general  principles  for  the  treatment  of 
chronic  tuberculosis  is  necessary  to  produce  a  satisfactory  convalescence, 
and  careful  attention  to  any  diseased  condition  that  may  be  present  in  the 
throat,  pharynx,  or  nose  is  necessary  to  prevent  a  return  of  this  condition. 

General  Miliary  Tuberculosis. — General  miliary  tuberculosis, 
whether  it  occurs  in  infancy  or  in  older  children,  is  a  fatal  disease,  and 
the  treatment,  therefore,  is  to  be  symptomatic,  always  applying  the  prin- 
ciples above  outlined  for  the  general  treatment  of  tuberculosis,  in  the  hope 
that  there  may  be  a  mistake  in  the  diagnosis.  Fresh  air,  proper  food, 
guaiacol  by  inunction  and  the  treatment  of  special  symptoms  should  be 
carefully  observed  until  a  fatal  termination  is  evident. 

Tuberculous  Bronchopneumonia. — Tuberculous  bronchopneumonia, 
at  whatever  age  it  may  occur,  should  be  treated  by  rest  in  bed,  fresh 
air,  proper  food,  guaiacol  inunctions,  the  inhalation  of  oxygen  and  warm 
baths.  Special  symptoms,  such  as  high  fever,  irritable  cough  and  gastro- 
intestinal complications,  should  be  dealt  with  in  the  manner  outlined  un- 
der the  treatment  of  ordinary  bronchopneumonia. 

Tuberculosis  of  the  Lungs  in  Older  Children. — This  is  to  be 
treated  as  phthisis  in  the  adult.  A  quiet  out-of-door  life  with  proper  food 
and  all  the  measures  previously  noted  in  the  treatment  of  chronic  tuber- 
culosis are  to  be  utilized.  Eest  in  bed  and  suitable  climatic  treatment 
are  more  urgently  demanded  in  this  form  of  tuberculosis  than  in  any 
other.  High  and  dry  air  in  a  moderately  bracing  and  equable  climate  is 
of  value.  The  symptomatic  treatment  is  the  same  as  in  the  adult;  the 
cough,  fever,  night  sweats,  and  other  troublesome  symptoms  are  to  be 
treated  as  in  the  adult. 

Tuberculous  Peritonitis. — Tuberculous  peritonitis  demands  rest, 
fresh  air,  a  most  carefully  selected  diet  looking  to  the  correction  of  the 
intestinal  complications,  guaiacol  inunctions  over  the  abdomen,  and  the 
careful  carrying  out  of  the  general  principles  above  outlined  for  the  treat- 
ment of  chronic  tuberculosis.  The  treatment  of  this  form  should  look  to 
the  correction  of  the  intestinal  complications;  carbonate  of  guaiacol,  in 
from  3-  to  5-grain  doses,  may  be  administered;  diarrhea  may  be 
treated  by  bismuth,  and  constipation  by  enemata.  Abdominal  pain  may 
be  relieved  by  the  application  of  heat,  and  sometimes  small  doses  of  pare- 
goric may  be  necessary.  Following  or  alternating  with  the  inunctions  of 
guaiacol  one  may  employ  inunctions  of  unguentum  Crede,  which  is  a 
remedy  of  value  in  many  of  these  cases.  If,  however,  the  disease  fails  to 
yield  to  this  treatment,  surgical  measures  may  be  resorted  to.  Laparotomy 
with  free  drainage  of  the  peritoneal  cavity  is  commonly  followed  by  im- 
provement which  not  infrequently  continues  to  a  final  recovery. 

Tuberculosis  of  Bones  and  Joints. — This  is  a  surgical  condition, 


403  ACUTE   ARTICULAR   RHEUMATISM 

the  special  treatment  of  which  is  outlined  in  works  on  general  and  ortho- 
pedic surgery.  The  general  treatment  above  outlined  should  accompany 
the  surgical  treatment. 


CHAPTER  XLV 

ACUTE  ARTICULAR  RHEUMATISM  AND  OTHER  FORMS  OP  ARTHRITIS 

ACUTE  ARTICULAR  RHEUMATISM 

Rheumatism  is  a  general  febrile  disease  of  infectious  origin,  its  chief 
manifestations  being  non-suppurative  polyarthritis,  acute  inflammatory 
disease  of  the  heart,  and  chorea.  One  or  all  of  these  manifestations  may 
be  present  in  the  same  case;  any  one  may  take  precedence  in  the  order  of 
their  development,  but  most  commonly  the  arthritis  precedes  the  heart 
disease  and  the  chorea.  These  latter  syndromes  are  elsewhere  considered. 
Acute  articular  rheumatism  is  the  term  generally  used  to  describe  the 
polyarthritis  and  its  associated  symptoms  produced  by  the  infectious 
agent  of  rheumatism.  It  is  most  important  that  this  broad  view  of  the 
nature  of  rheumatism  be  kept  in  mind,  since  the  articular  manifestations 
in  early  life  are  sometimes  so  slight  that  it  will  bo  altogether  overlooked, 
unless  the  general  character  of  the  disease  is  recognized  and  the  impor- 
tance of  other  symptoms  taken  into  consideration  in  making  the  diagnosis. 
Rheumatism  in  childhood  is  not  simply  an  arthritis;  it  is  a  general  infec- 
tion in  which  the  arthritis  may  or  may  not  j)lay  the  most  important  role. 
For  this  broader  view  of  the  nature  of  rheumatism  we  are  largely  in- 
debted to  Chcadle.  Barlow  and  their  followers. 

Etiology. — Rheumatism  is  generally  recognized  as  an  acute  infection, 
but  as  yet  the  specific  microorganism  which  produces  this  disease  lias  not 
been  positively  determined.  It  occurs,  as  a  rule,  sporadically,  but  may  also 
appear  in  epidemic  form.  It  is  believed  that  the  contagion  usually  enters 
the  body  through  the  lymphatic  ring  of  which  the  tonsils  and  adenoids 
are  a  part,  and  in  doing  so  may  produce  acute  inflammation  of  this  lymph- 
atic tissue.  Heredity  is  an  important  predisposing  factor.  There  is  no 
doubt  but  that  the  members  of  certain  families  are  predisposed  to  rheu- 
matism. This  hereditary  taint  in  many  instances  is  related  to  the  gouty 
diathesis.  The  individual  may  inherit  arthritism.  or  a  susceptibility  to 
inflammations  of  serous  membranes,  and  by  reason  of  this  inheritance 
offer  but  feeble  resistance  to  the  rheumatic  poison.  Rheumatism  is  more 
common  in  cold,  moist  climates  and  is  more  frequently  seen  during  the 
spring  of  the  year.  Exposure  to  damp  cold  has  long  been  recognized  as 
an  exciting  factor.  Rheumatism  is  extremely  rare  under  two  years  of 
age.  uncommon  under  five,  but  between  the  seventh  and  fifteenth  year  of 
life  it  is  almost  as  frequently  observed  as  it  is  in  adult  life.  It  is  slightly 
more  common  in  girls  than  in  boys. 


ACU'Jl^:   ARTICULAR   RHEUMATISM!  403 

Symptomatology. — In  children  over  twelve  years  of  age  the  onset  is 
commonly  sudden,  as  it  is  in  the  adult.  The  disease  is  ushered  in  with 
chilly  sensations,  ■  followed  by  a  rapid  rise  in  temperature  which  may  reach 
104°  or  105°  F.  This  is  accompanied  by  a  sharp  inflammation  of  one  of 
the  ankle  or  knee  joints.  The  swelling,  redness,  and  pain  rapidly  increase 
until  the  joint  becomes  extremely  painful  to  motion  and  exquisitely  sensi- 
tive to  touch.  These  symptoms  are  associated  with  an  acid  perspiration, 
and  the  disease  quickly  spreads  to  other  Joints,  producing  the  typical 
rheumatic  polyarthritis  seen  in  the  adult.  The  patient,  prostrate  and 
helpless,  cries  with  jiain  when  the  inflamed  joints  are  moved  or  touched. 
This  is  the  picture  seen  in  the  adult,  and  sometimes  in  the  older  child, 
but  it  is  in  strange  contrast  to  the  clinical  picture  of  acute  articular  rheu- 
matism in  the  young  child,  where  the  arthritis  may  be  so  slight  as  to 
almost  escape  attention,  and  where  in  many  instances  the  child  remains 
upon  its  feet  until  attention  is  called  to  its  slightly  tender  joints  and  its 
slight  elevation  of  temperature,  by  the  development  of  acute  endocarditis 
or  some  other  manifestation  of  the  rheumatic  poison.  Between  these  two 
extreme  clinical  pictures  the  severity  of  the  disease  may  vary;  on  the 
whole,  however,  it  should  be  remembered  that  in  the  child  it  is  less  vio- 
lent in  its  onset  and  much  milder  in  its  arthritis,  and  that  cardiac  mani- 
festations are  much  more  common  and  severe  than  they  are  in  the  adult. 
The  younger  the  child  the  milder  the  joint  symptoms  is  a  rule  which  may 
have  its  exceptions.  In  the  average  case  prodromal  symptoms  are  present, 
such  as  anorexia,  languor,  catarrhal  sore  throat,  abdominal  pain,  and  slight 
fever.  In  these  prodromes  there  is  nothing  distinctive  and  the  nature  of 
the  disease  is  not  suspected  until  careful  examination  reveals  tender  and 
slightly  swollen  joints.  Rheumatic  polyarthritis  is  not  so  widespread  in 
the  child  as  it  is  in  the  adult.  It  most  commonly  occurs  in  the  knee, 
ankle,  wrist  and  elbow  joints,  and  later  may  spread  to  the  fingers,  toes, 
hips  and  vertebra.  Barlow  called  attention  to  the  frequency  with  which 
the  hip  joint  is  involved  in  childhood.  The  acute  inflammation  in  a  joint 
rarely  lasts  longer  than  one  or  two  days,  and  usually  not  more  than  two 
joints  are  aciitely  inflamed  at  the  same  time.  The  disease,  spreading 
from  joint  to  joint,  may  prolong  the  fever  and  arthritis  from  one  to  three 
weeks.  Muscular  pain  and  tenderness  are  common  symptoms  of  rheu- 
matism in  childhood ;  they  are  due  to  inflamftiation  of  the  fascia,  and  are 
usually  more  marked  near  the  joints;  niany  of  the  "growing  pains"  are 
due  to  this  cause.  Rheumatic  wry-neck  is  not  infrequent ;  it  is  caused  hy 
tonic  contractions  of  the  sternocleidomastoid,  which  last  two  or  three  days 
and  are  not  intermittent,  as  they  are  in  malarial  wry-neck.  This  symp- 
tom is  associated  with  some  pain  and  marked  tenderness  of  the  muscle. 
Rheumatic  nodules  are  small,  fibrous  nodes,  varying  in  size  from  a  bird- 
shot  to  a  buck-shot,  located  near  the  joints  and  along  the  tendons.  They 
are  found  especially  about  the  wrists,  elbows,  knees,  knuckles,  and  ver- 
tebra. They  may  be  felt  more  readily  than  seen.  When  present,  however, 
thev  are  easily  brought  out  by  stretching  the  skin  over  these  joints.     In 


404  ACUTE  ARTICULAR   RHEUMATIS:\r 

England  these  nodules  are  common  and  are  classed  among  the  valuable 
diagnostic  signs  of  rheumatism  in  the  child.  In  America,  however,  they 
are  comparatively  rare.  Tonsillitis  is  a  very  common  rheumatic  manifesta- 
tion. It  occurs,  as  a  rule,  as  one  of  the  initial  symptoms,  especially  in 
second  and  third  attacks  of  this  disease.  The  anemia  caused  by  rheumatism 
is  well  marked  and  ])rogressive.  There  arc  few  diseases  tliat  produce  so 
great  a  destruction  of  hemoglobin  and  red  blood  corpuscles  in  the  same 
length  of  time.  Neurotic  disorders  are  among  the  late  manifestations ;  they 
are  perhaps  due  to  the  anemia  and  may  continue  for  many  weeks  or  even 
months  after  convalescence  is  established.  The  rheumatic  child  is  highly 
excitable,  irritable,  sleeps  restlessly  and  may  suffer  from  night-terrors,  in- 
continence of  urine,  habit  spasm,  and  other  neurotic  disorders.  The  acid 
perspiration,  so  common  in  the  adult,  is  not  present  in  the  child. 

Heart  disease  occurs  in  more  than  half  of  the  cases;  endocarditis  is 
very  common;  pericarditis  and  myocarditis  occur  less  frequently.  These 
conditions  are  described  in  another  chapter,  but  the  facts  should  here  be 
emphasized  that  disease  of  the  heart  occurs  much  more  frequently  as  a 
rheumatic  manifestation  in  the  child  than  it  does  in  the  adult,  and  that 
the  frequency  and  severity  of  the  cardiac  disease  are  in  no  way  related  to 
the  severity  of  the  arthritic  symptoms.  A  case  of  rheumatism  with  little 
or  no  arthritis  may  develop  a  fatal  heart  disease.  It  is  due,  therefore, 
to  the  frequency  and  severity  of  the  cardiac  lesions  that  rheumatism  in 
childhood  is  such  a  serious  disease.  Chorea  is  a  common  manifestation  of 
the  rheumatic  poison.  This  syndrome  may  precede  or  follow  either  the 
arthritis  or  the  heart  disease.  Pleurisy  and  iritis  are  rare  manifestations 
of  the  rheumatic  poison.  Various  skin  eruptions  may  occur ;  the  most  im- 
portant of  these  are  purpura,  erythema  multiforme,  and  erythema  nodosum. 

Diagnosis. — If  the  clinical  picture  of  this  disease,  as  it  is  presented  in 
childhood,  be  ever  kept  in  mind,  there  should  be  little  difficulty  in  making 
an  early,  accurate  diagnosis.  The  certainty  with  which  the  salicylates 
modify  or  control  the  symptoms  may,  in  doubtful  cases,  be  an  important 
aid  to  diagnosis.  An  acute  syndrome  resembling  rheumatism  that  is  not 
in  any  way  influenced  by  the  salicylates  is,  as  a  rule,  not  rheumatic. 
Again  it  should  be  remembered  that  rheumatism  is  extremely  rare  during 
the  first  two  years  of  life,  and  is  uncommon  before  the  fifth  year.  A 
syndrome  presenting  joint  symptoms  resembling  rheumatism  in  the  adult, 
occurring  in  a  child  under  three 'years  of  age,  is  almost  without  exception 
not  rheumatic.  Scurvy  is  the  condition  most  commonly  mistaken  for 
rheumatism  in  infancy,  but  this  is  simply  because  the  physician  has  in 
mind  the  adult  type  of  rheumatism  and  has  out  of  mind  the  syndrome 
of  scurvy  (see  Scurvy).  Syphilitic  arthritis  is  an  afebrile  condition  which 
should  easily  be  excluded  by  the  absence  of  other  syphilitic  symptoms. 
Septic  arthritis,  which  occurs  as  a  common  manifestation  of  septicemia 
and  septicopyemia,  is  frequently  mistaken  for  rheumatism  in  childhood; 
the  following  clinical  characteristics,  however,  should  differentiate  it  from 
this  disease.    It  follows  some  acute  infection  such  as  influenza,  scarlet  fever, 


ACUTE   AETICULAR   RHEUMATISM  405 

diphtheria,  gonorrhea  or  pneumonia;  the  joints  are  acutely  and  sometimes 
very  violently  inflamed,  and  pus  formation  is  common;  it  may  run  a 
more  or  less  chronic  course,  the  fever  is  septic  in  type,  the  joint  symptoms 
are  uninfluenced  by  salicylates,  a  blood  examination  shows  well-marked 
leukocytosis,  and  the  pus,  aspirated  from  the  joint,  may  determine  the 
specific  organism  producing  the  inflammation.  Acute  osteomyelitis  may 
be  mistaken  for  rheumatism,  but  here  also  the  high  fever,  marked  con- 
stitutional symptoms,  and  pronounced  swelling  and  tenderness  which  oc- 
cur near  but  not  in  the  joint   should  make  the  diagnosis  plain. 

Prognosis. — The  prognosis,  so  far  as  the  joint  symptoms  are  concerned, 
is  good.  The  arthritis  quickly  disappears,  leaving  the  joints  entirely  free 
from  pain  and  tenderness,  and  recurring  attacks  do  not,  except  in  rare 
instances,  produce  the  chronic  thickening  and  tenderness  of  the  joints  so 
frequently  seen  in  the  adult.  The  cardiac  lesions,  however,  which  are  so 
commonly  caused  by  rheumatism,  are  always  serious  and  sometimes  fatal. 
Treatment. — With  the  onset  of  symptoms  indicating  an  attack  of 
rheumatism,  the  patient  should  be  put  to  bed  in  a  well-ventilated  room, 
the  temperature  of  which  should  be  kept  between  65°  and  70° F.  through- 
out the  attack.  As  a  rule  it  is  advisable  to  keep  the  patient  in  bed  for  one 
or  two  weeks  after  all  acute  symptoms  have  disappeared.  This  commonly 
covers  a  period  of  four  or  five  weeks.  Rest  in  bed  modifies  the  severity 
of  the  attack,  diminishes  the  dangers  of  cardiac  complications,  insures  a 
more  satisfactory  convalescence  and  prevents  relapses.  The  diet  through- 
out the  acute  attack  should  be  milk,  bread  and  cereals,  and  with  the  begin- 
ning of  convalescence  chicken  and  mutton  broths  thickened  with  cereals, 
purees  of  vegetables,  and  eggs  may  be  allowed.  When  the  joints  are  acutely 
inflamed  they  should  be  incased  in  thick  layers  of  cotton-wool,  wrapped 
with  bandages,  and  immobilized  by  light  splints  outside  the  cotton-wool 
dressing.  They  may  also  be  protected  from  the  weight  of  the  bed-clothing 
by  shields. 

Medical  Treatment. — This  should  be  begun  with  a  dose  of  one  or 
two  grains  of  calomel  followed  by  Rochelle  salts,  and  throughout  the  attack 
the  bowels  are  to  be  kept  open  with  sodium  phosphate,  sodium  sulphate 
or  some  other  saline  laxative.  Immediately  following  the  preliminary 
cathartic,  the  salicylate  treatment  should  be  begun.  In  the  great  majority 
of  cases  the  wintergreen  salicylate  of  soda  combined  with  the  bicarbonate 
of  soda  will  give  the  best  results.  But  other  salicylates  such  as  aspirin 
and  salol  may  be  used. 

;r     Sodii  salicylatis   (wintergreen) 3    i 

Sodii   bicarbonatis    3   i 

Syrupi    aiirantii     3    iv 

Aquae  menth  pip   ad    |   ii 

Sig.  Teaspoonful  every  four  hours  for  a  child  four  or  five  years  of  age. 

There  is  no  difference  of  opinion  as  to  the  value  of  salicylates  in  these 
cases.     The  only  objection  to  their  continuous  administration  is  that  it 


406  ACUTE   ARTICULAR   RHEUMATISM 

may  nauseate  and  otherwise  disturb  the  digestive  organs;  to  avoid  this 
the  vehicle  carrying  them  should  be  carefully  selected  and  changed  from 
tinie  to  time  if  necessary.  The  action  of  the  salicylates  in  rheumatism 
is  to  a  certain  extent  specific;  they  reduce  the  fever,  lessen  the  pain,  and 
perhaps  shorten  the  attack.  It  is  also  believed  that  both  the  alkalies  and 
salicylates  diminish  the  danger  of  cardiac  complications.  As  the  acute 
symptoms  come  under  control,  the  dose  of  the  salicylate  is  to  be  diminished 
one-half,  and  continued  until  the  fever  and  arthritis  have  entirely  disap- 
peared; but  the  alkaline  treatment  is  to  be  continued  for  weeks  after  the 
child  is  convalescent.  If  the  anemia  of  this  disease  persists  for  two  or 
three  weeks  after  the  acute  symptoms  have  disappeared,  some  form  of 
organic  iron  and  of  arsenic  combined  with  malt  may  be  given  after  meals. 
Cod-liver  oil  may  also  be  a  valuable  tonic.  If  heart  complications  appear 
during  the  acute  attack  an  ice-bag  is  to  be  intermittently  applied  over  the 
cardiac  region,  absolute  quiet  insisted  upon,  and  this  complication  is  to  be 
further  treated  as  outlined  in  the  section  on  The  Heart. 

Treatment  of  the  Interval. — If  the  season  be  winter  the  child 
should  be  sent  to  a  warm,  dry  climate,  to  complete  its  convalescence.  Out- 
door life  in  an  equable,  warm,  dry  climate  will  quickly  restore  the  child's 
health  and  strength.  On  its  return  home  in  the  spring  of  the  year,  the 
throat  and  nose  should  be  carefully  examined,  and,  if  necessary,  diseased 
tonsils,  adenoids  and  other  growths  should  be  removed,  so  that  during 
the  summer  the  child's  throat  and  upper  respiratory  passages  can  be  got- 
ten into  a  condition  to  resist  the  common  catarrhal  conditions  so  prevalent 
during  the  winter  months.  During  all  of  this  time  constipation  and  over- 
feeding are  to  be  carefully  avoided.  It  is  most  important  that  the  child 
should  have  sufficient  food  of  proper  character  to  serve  nutritional  pur- 
poses, but  in  many  of  these  children  it  will  be  found  that  they  are  taking 
from  one-half  to  one-third  more  food  than  is  actually  necessary.  The 
caloric  value  of  the  child's  food  should  therefore  be  determined,  that  one 
may  be  sure  that  he  is  not  being  overfed  and  thus  overtaxing  the  excretory 
organs.  During  all  of  this  time  he  should  live  on  a  simple  general  diet, 
composed  of  vegetables,  cereals,  bread,  meats  of  all  kinds,  eggs,  cooked 
fruits  and  especially  milk,  avoiding,  sweets,  tea,  coifee.  strong  beef  broth 
and  raw  food  of  all  kinds.  No  medication  perhaps  is  necessary,  except  an 
occasional  cathartic  or  a  course  of  bicarbonate  of  soda,  or  some  other 
alkali,  if  the  urine  becomes  hyperacid  and  the  child  becomes  nervous  and 
irritable.  The  underclothing  shoiild  be  of  wool,  and  this  should  only  be 
discarded  for  cotton  underwear  during  the  hot  summer  months.  These 
children  should  be  kept  under  medical  supervision  for  years,  and  during 
all  of  this  time  protected  from  damp,  cold  weather,  and  yet  be  out-of- 
doors  as  much  as  possible;  the  best  results  are  obtained,  therefore,  in 
changing  the  climate  with  the  season  so  that  they  may  live  as  much  as 
possible  out-of-doors  in  a  warm,  dry  climate.  It  will  not  be  possible  to 
furnish  such  ideal  conditions  for  all  of  our  patients;  most  of  them  must 
be  treated  at  home,  but  in  the  home  treatment  the  same  principles  must 


OTHER    FORMS    OF    ARTHRITIS  407 

be  carried  out  and  the  physician's  judgment  may  sometimes  be  taxed  to 
determine  in  an  individual  case  whether  an  indoor  life  will  do  more  harm 
than  exposure  to  the  damp,  cold  weather,  which  is  so  prevalent  during  the 
winter  months  in  the  temperate  zone. 

OTHER  FORMS  OF  ARTHRITIS 

In  addition  to  the  arthritis  which  occurs  in  tuberculosis,  gonorrhea, 
syphilis,  scurv}^,  rickets,  purpura  rheumatica,  and  other  hemorrhagic  dis- 
eases, there  are  other  forms  which  may  be  confused  with  true  rheumatism 
and  which  have  been  described  under  the  following  names :  Infectious 
Arthritis,  Chronic  Villous  Arthritis,  Chronic  Rheumatoid  Arthritis. 

INFECTIOUS    ARTHRITIS 

Infectious  arthritis  is  an  acute  pyogenic  infection  involving  one  or 
more  joints. 

Etiology. — It  commonly  occurs  as  a  symptom  or  complication  of  the 
acute  infections,  such  as  tonsillitis,  scarlet  fever,  influenza,  diphtheria, 
pneumonia,  cerebrospinal  meningitis,  and  septicopyemia.  It  may  be  pro- 
duced by  a  variety  of  microorganisms,  the  most  common  of  which  are 
streptococci,  staphylococci  and  pneumococci. 

Symptomatology. — The  joint  or  joints  involved  become  swollen,  red, 
tender,  and  fluctuation  sooner  or  later  develops.  The  aspirating  needle  re- 
veals the  character  of  the  fluid,  and  from  the  fluid  thus  obtained  the  spe- 
cific organisms  producing  the  inflammation  may  be  isolated.  The  fever 
in  these  cases  is  irregular  or  septic  in  type ;  the  pain  and  tenderness  of  the 
joints  and  the  fever  are  uninfluenced  by  salicylates,  and  the  blood  shows 
a  marked  leukoc)i;osis.  Infectious  arthritis  may  be  associated  with  or 
may  follow  osteomyelitis.  In  such  cases  the  constitutional  symptoms  are 
much  more  pronounced,  there  is  evidence  of  general  sepsis  and  the  swell- 
ing and  tenderness  extend  from  the  joints  into  the  bones. 

Treatment. — This  is  a  surgical  condition  and  operative  measures  are 
usually  necessary  for  its  relief.  Following  the  opening  and  draining  of 
the  infected  joints,  if  convalescence  does  not  readily  set  in,  autogenous 
vaccines  should  be  tried.  In  most  cases  recovery  is  followed  by  more  or 
less  complete  ankylosis.  Later  when  all  inflammation  has  subsided  mas- 
sage and  active  and  passive  motion  of  the  joint  may  be  resorted  to,  in  the 
hope  of  partially  restoring  its  function. 

CHRONIC    VILLOUS    AETHRITIS 

Chronic  villous  arthritis  is  a  low  inflammatory  affection  of  the  synovial 
membranes,  which  results  in  hypertrophy  of  the  villi  of  the  joint  surfaces ; 
one  or  more  joints  may  be  involved.  The  etiological  factors  of  this  con- 
dition are  unknown,  but  it  is  not  uncommonly  associated  with  other  joint 
diseases. 

Symptomatology. — There  is  little  or  no  fever,  the  disease  runs  a  very 


408  ACUTE    AETICULAR    RHEUMATISM 

chronic  course,  the  joints  involved  gradually  increase  in  size  and  assume 
a  more  or  less  waxy  appearance ;  they  are  slightly  tender,  and  after  a  time 
become  more  or  less  ankylosed  and  remain  chronically  enlarged.  This 
condition  may  be  mistaken  for  a  tuberculous  arthritis,  but  the  absence  of 
other  signs  and  symptoms  of  tuberculosis,  together  with  an  X-ray  pic- 
ture showing  no  bone  changes  in  the  joints  involved,  should  clear  the 
diagnosis. 


CHRONIC    RHEUMATOID    ARTHRITIS 
(Arthritis   Deformans,   Still's   Disease) 

Under  the  above  names  are  described  a  group  of  comparatively  rare 
arthritides  which  occur  in  children,  involving,  as  a  rule,  many  joints,  run- 
ning a  very  chronic  course  and  leaving  the  joints  more  or  less  disabled. 

Etiology. — This  condition  may  be  associated  with  chronic  intestinal 
intoxication,  some  defect  in  metabolism  or  some  more  or  less  obscure 
infection. 

Symptomatology. — The  onset  may  be  sudden  or  it  may  be  gradual,  but 
in  all  of  these  cases  in  the  beginning  there  is  fever,  mild  or  severe,  with 
more  or  less  soreness,  pain  and  swelling  of  the  joints  of  both  the  upper  and 
lower  extremities.  After  a  time  the  acute  inflammatory  symptoms  in  the 
joints  gradually  subside,  leaving  them  more  or  less  deformed  or  disabled. 
In  some  cases  there  are  repeated  attacks  of  acute  inflammation  of  the 
joints  marked  by  increased  swelling,  tenderness,  and  perhaps  by  a  slight 
rise  of  temperature.  With  these  repeated  attacks  the  joints  are  left  more 
and  more  deformed  and  disabled.  In  one  group  known  as  Hypertrophic 
Arthritis  the  condition  resembles  arthritis  deformans;  in  these  cases  the 
bones  about  the  joint  hypertrophy,  exostoses  form,  a  marked  nodular 
deformity  of  the  joint  results,  and  its  function  is  gradually  lost.  In 
another  group,  spoken  of  as  Atrophic  Arthritis,  the  tissues  about  the  joint 
atrophy,  and  ankylosis  occurs  from  the  inflammatory  adhesions  of  the  joint 
surfaces;  in  these  cases  the  nodular  deformities  about  the  joint  are  not 
so  great.  In  a  third  group.  Still's  Disease,  there  is  associated  with 
the  rheumatoid  arthritis  enlargement  of  the  lymph  nodes,  spleen, 
and  sometimes  the  liver,  and  marked  leukocytosis  is  present ;  the 
lymph  nodes  especially  enlarged  are  the  axillary,  epitrochlear  and  posterior 
cervical. 

Prognosis. — The  prognosis  so  far  as  life  is  concerned  is  good,  but  the 
majority  of  these  cases  become  crippled  and  deformed.  A  certain  per- 
centage, however,  especially  those  associated  with  chronic  intestinal  intox- 
ication, may  be  greatly  benefited  and  a  small  percentage  entirely  recover. 

Treatment. — If  the  underlying  intoxication  can  be  discovered,  treat- 
ment should  be  directed  toward  its  removal.  It  is  most  important  in 
all  cases  to  give  attention  to  the  gastrointestinal  canal.     Careful  feeding 


OTHER    FORMS    OF    ARTHRITIS  409 

to  suit  the  age  and  digestive  capacity  of  the  individual  and  fresh  air, 
night  and  day,  are  our  most  important  remedial  measures.  During  the 
acute  inflammatory  stage  of  the  arthritis  the  joints  should  be  fixed  and 
carefully  protected  by  appropriate  dressings.  After  the  acute  stage  has 
disappeared  and  all  tenderness  and  evidences  of  inflanmiation  in  the  joints 
have  subsided,  massage,  passive  movements,  and  hydrotherapy  may  be  of 
value  in  partially  restoring  the  lost  motion. 


SECTION   VII 
DISEASES  OF  THE  RESPIRATOBY  SYSTEM 

The  nasal  cavity  of  the  j'oung  child  is  much  smaller  than  that  of  the 
adult.  In  the  newborn  it  is  so  narrow  that  slight  swelling  of  the  mucous 
membrane  may  cause  its  occlusion.  The  accessory  sinuses  of  the  nose  are 
but  poorly  developed,  so  that  one  rarely  sees  in  the  infant  and  very  young 
child  infections  of  the  ethmoidal  and  frontal  sinuses.  On  the  other  hand, 
the  Eustachian  tube  is  unusually  patulous  in  the  young  child,  so  that  in- 
flammatory processes  of  the  pharynx  are  much  more  readily  communicated 
to  the  middle  ear.  The  tear  ducts  in  the  infant  and  child  are  also  more 
patulous,  and  more  readily  carry  inflammation  from  the  nose  to  the  eye. 
Catarrhal  inflammations,  therefore,  of  the  ear  and  the  conjunctiva  are 
much  more  common  complications  of  the  catarrhal  diseases  of  the  res])ira- 
tory  passages  in  the  young  child  than  they  are  in  the  adult.  The  thorax 
is  more  cylindrical  than  in  the  adult,  and  the  ribs  are  soft  and  flexible, 
being  composed  largely  of  cartilaginous  tissue.  This  flexibility  makes  it 
possible,  when  there  is  difficulty  in  getting  air  into  the  lungs,  for  the 
diaphragm,  by  reason  of  its  forceful  contraction,  to  cause  the  chest  to  sink 
in  and  produce  the  peripneumonic  groove  where  the  diaphragm  is  at- 
tached to  the  chest  wall.  This  peripneumonic  inspiratory  recession  of  the 
chest  is  one  of  the  characteristic  signs  of  dyspnea  in  the  young  infant. 
The  softness  and  pliability  of  the  ribs  in  early  infancy  is  more  marked  in 
rachitic  infants.  Children  of  this  type,  when  subjected  to  more  or  less 
inspiratory  obstruction  over  a  long  period  of  time,  may  have  chronic 
deformities  of  the  chest,  such  as  pigeonbreast  and  depressions  of  the  chest 
wall  about  the  lower  end  of  the  sternum. 

The  respiratory  rhythm,  like  the  heart  rhythm  of  the  young  infant, 
may  be  very  irregular  without  indicating  a  pathological  condition.  Tlie 
frequency  of  respirations,  like  the  pulse  rate  of  the  infant,  may  be  affected 
by  insignificant  causes,  and  varies  greatly  within'  normal  limits.  Excite- 
ment, anger,  slight  toxic  conditions,  and  even  reflex  irritations  caused  l)y 
pain  in  the  intestinal  canal,  the  ear.  or  elsewhere  may  produce  a  marked 
acceleration  of  the  respiratory  rate. 

The  thoracic  muscles  of  the  infant  are  poorly  developed,  but  the  dia- 
phragm and  abdominal  muscles  are  well  developed.  The  child  breathes 
and  cries  with  its  diaphragm  and  abdominal  muscles.  The  type  of  breath- 
ing in  both  sexes  is  largely  abdominal.     The  costal  type  commences  to  be 

410 


ACUTE    RHINITIS 


411 


manifest  in  the  male  child  at  about  the  ninth  or  tenth  year  of  life.  The  fol- 
lowing table  shows  the  comparative  frequency  of  the  pulse  and  respira- 
tions at  different  periods  of  child  life : 


Infant. 

Respiration    50-30 

Pulse     130-120 

Ratio    1  to  3  or  4 


1st  to  2d  year.  4th  to  6th  year.  8th  to  10th  year. 

25  20                        18 

100-95  90                         85 

1  to  4  1  to  41/2          1  to  4y2  or  5 


CHAPTER    XLVI 

DISEASES     OF    THE     NASAL     MUCOUS     MEMBRANE 


ACUTE   RHINITIS 

(Acute  Coryza,  Acute  Nasal  Catarrh) 

This  is  a  catarrhal  inflammation  of  the  nasal  raucous  membrane  which 
very  commonly  involves  the  pharynx  and  tonsils. 

Etiology. — Infection  is  the  prime  and  all-important  cause  of  rhinitis. 
This  catarrhal  inflammation  may  be  produced  by  a  great  variety  of  micro- 
organisms, chief  among  which  are  the  pneumococcus,  streptococcus,  staphy- 
lococcus, bacillus  catarrhalis.  and  influenza  bacillus.  It  may  also  be 
caused  by  the  pathogenic  organisms  which  produce  measles,  diphthe- 
ria, scarlet  fever,  and  cerebrospinal  meningitis;  rhinitis,  therefore, 
is  a  lesion  producing  a  rather  definite  clinical  syndrome,  rather  than  a 
disease  sui  generis.  While  microorganisms  are  the  essential  cause  of  this 
condition,  it  should  be  remembered  that  the  mucous  membrane  of  the  nose 
is  normally  in  a  condition  to  resist  infection  from  most  of  these  organ- 
isms; in  fact  the  bacteria  capable  of  producing  a  rhinitis  may  usually  be 
found  on  the  nasal  mucous  membranes  of  normal  children.  At  times  the 
disease  occurs  in  epidemic  form,  being  produced  by  the  bacteria  of  epi- 
demic grippe,  but  the  fact  that  the  ordinary  or  sporadic  form  is  not  in- 
frequently produced  by  microorganisms  which  the  normal  mucous  mem- 
brane of  the  nose  is  capable  of  resisting,  shows  the  importance  of  predis- 
posing factors.  These  factors  may  produce  a  trauma,  a  congestion,  or  an 
irritation  of  the  nasal  mucous  membrane  or,  by  acting  through  constitu- 
tional influences,  may  so  reduce  its  resisting  power  that  bacteria  which  are 
commonly  present  are  enabled  to  start  an  acute  catarrh  and  develop  a 
well-marked  rhinitis.  Among  these  predisposing  causes  may  be  mentioned : 
traumas  to  the  mucous  membrane  from  chemical  and  mechanical  causes, 
exposure  to  dry  air  in  superheated  apartments,  or.  more  important  than 
all,  exposure  to  damp  cold,  unprotected  by  proper  clothing.  This  latter 
predisposing  cause  is  the  one  ordinarily  spoken  of  by  the  laity  as  "catching 
cold,"  and  there  can  be  no  question  but  that  it  is  an  important  and  com- 


412       DISEASES   OF   THE   NASAL   MUCOUS   MEMBEANE 

mon  predisposing  cause  not  only  of  rhinitis,  but  of  all  catarrhal  diseases 
of  the  resi^iratory  mucous  membranes. 

Ehinitis  is  most  common  in  the  cold,  damp  months  of  winter  and 
spring,  because  the  conditions  for  "catching  cold''  and  for  contracting 
contagion  are  very  much  better  during  these  seasons.  Mild  cases  of  rhi- 
nitis are  also  very  common  during  the  dry  fall  months  of  the  year,  when 
the  mucous  membrane  is  so  constantly  irritated  with  a  dust-laden  at- 
mosphere. The  particles  of  dust  may  act  as  carriers  of  bacteria  and  as 
irritants  to  the  mucous  membrane,  thus  preparing  the  soil  for  the  seed 
which  is  carried  to  it.  Subacute  or  chronic  diseases  of  the  tonsils  and 
adenoid  tissues  may  be  the  cause  of  repeated  attacks  of  rhinitis.  Constitu- 
tional diseases,  especially  syphilis  and  tuberculosis,  are  so  commonly  asso- 
ciated with  rhinitis  that  this  s3'mptom  group  is  described  as  a  part  of  the 
symptomatology  of  these  two  diseases.  Other  malnutritions  which  produce 
anemia  and  diminish  the  general  resistance  may  be  predisposing  causes. 
Ehinitis  is  one  of  the  important  symptom  groups  of  hay  fever.  There  is 
a  recurring  form,  probably  due  to  autotoxins,  which  is  described  under 
Nutritional  Disorders. 

Symptomatology. — The  onset  is  marked  by  an  irritation  of  the  mucous 
membrane  of  the  nose,  which  manifests  itself  by  redness  and  swelling; 
sneezing  is  a  common  and  early  symptom.  As  a  rule  there  is  a  slight 
elevation  of  temperature  associated  with  headache,  lassitude,  sleeplessness, 
nervousness,  and  more  or  less  general  discomfort.  Early  in  the  disease 
the  nasal  discharge  is  thin  and  watery,  being  serous  in  character.  In  a 
few  days  this  discharge  becomes  thicker  and  more  tenacious,  being  com- 
posed of  heavier  mucus;  later  it  may  become  mucopurulent.  In  gonococ- 
cic,  diphtheritic  and  scarlatinal  infections  the  discharge  is  always  puru- 
lent. The  irritating  character  of  the  discharge  in  ordinary  rhinitis  varies 
greatly.  Not  infrequently  the  nasal  openings  and  the  underlying  portion 
of  the  lip,  over  which  the  discharge  runs,  are  irritated,  red,  excoriated  and 
sometimes  covered  with  dry  scales,  or  scabs,  which  may  partially  or  com- 
pletely block  up  the  nasal  opening.  Ehinitis  is  a  comparatively  insig- 
nificant disease,  which  runs  a  mild  course,  terminating  in  recovery  in 
from  three  to  five  days.  The  great  majority  of  the  cases  are  fortunately 
of  this  type.  In  the  very  young  infant  the  disease  is  much  less  commonly 
seen,  but  when  it  does  occur  it  is  a  source  of  much  greater  anxiety  to  the 
physician,  not  only  because  it  is  more  likely  to  extend  through  the  pharynx 
to  the  bronchial  mucous  membrane,  but  also  because  even  simple  rhinitis 
at  this  age  is  a  troublesome,  sometimes  serious,  and  rarely  dangerous  af- 
fection, because  the  swelling  of  the  nasal  mucous  membrane  not 
infrequently  occludes  the  narrow  nasal  passages  of  the  young  infant,  and 
when  this  occurs  it  may  have  great  difficulty  in  sleeping,  breathing,  and 
taking  food.  The  very  young  infant,  not  being  accustomed  to  breathe 
through  its  mouth,  may  be  put  in  a  perilous  position  by  having  its  nasal 
passages  occluded;  dyspnea,  severe  attacks  of  asphyxia,  and,  in  rare  in- 
stances, even  death  may  result  from  nasal  stenosis;  this,  however,  is  a  very 


ACUTE    RHINITIS  413 

rare  occurrence.  The  taking  of  food  in  these  cases  is  always  more  or  less 
interfered  with;  the  infant  often  cannot  nurse  either  from  the  breast  or 
from  a  bottle,  since  it  must  let  go  of  the  nipple  to  get  its  breath;  it  may 
be  necessary  to  feed  with  a  spoon. 

Cough. — In  simple,  uncomplicated  rhinitis  cough  is  usually  absent, 
but  in  the  majority  of  cases  the  disease  extends  to  the  pharynx  and  some- 
times to  the  larynx.  Irritation  in  either  of  these  regions  may  produce  a 
cough,  the  character  of  which  may  mark  the  progress  of  the  disease.  The 
pharyngeal  cough  frets  the  infant  and  is  sharp  and  irritating;  as  the 
disease  progresses  into  the  larynx,  the  characteristic  croupy  cough,  later 
to  be  described,  makes  its  appearance. 

Fever. — Ehinitis  may  run  its  course  with  little  or  no  fever;  however, 
there  is  usually  a  slight  elevation  of  temperature  in  the  beginning  of  the 
disease.  In  the  epidemic  forms  associated  with  grippe  and  other  con- 
tagious diseases  the  temperature  at  the  onset  may  be  high;  this  is  not  due 
to  the  coryza,  but  to  the  general  infection  of  which  the  coryza  is  a  symp- 
tom. Later  in  the  disease,  as  the  rhinitis  is  running  its  course,  apparently 
in  a  satisfactory  manner,  we  may  have  a  sudden  and  marked  elevation  of 
temperature,  the  fever  reaching  104°  or  105°F.  within  a  few  hours;  this 
commonly  means  the  onset  of  an  acute  otitis  media.  This  complication 
demands  immediate  surgical  attention;  an  early  incision  of  the  drum 
may  save  not  only  much  suffering,  but  a  possible  mastoid  infection.  Ear- 
ache commonly  precedes  the  otitis  media;  but  in  some  instances,  especially 
in  malnourished,  tuberculous  children,  a  discharge  from  the  ear  is  the 
first  indication  of  this  complication. 

Pharyngitis,  tonsillitis,  and  inflammation  of  the  adenoid  tissue  of  the 
pharynx  are  frequently  associated  with  coryza.  Catarrhal  inflammation 
in  the  nose  not  infrequently  spreads  to  the  eye,  producing  a  mild,  or  even 
a  pronounced,  conjunctivitis;  this  may  occur  in  epidemic  form,  and  is 
then  commonly  spoken  of  as  "pink  eye."  The  conjunctivitis  may  precede 
the  coryza,  but  commonly  the  reverse  is  true. 

Pseudomembranous  rhinitis  should  always  be  looked  upon  as  diph- 
theritic, until  it  has  been  definitely  demonstrated  to  be  due  to  other  causes. 
The  safest  plan  in  these  cases  is  to  give  a  dose  of  diphtheria  antitoxin,  and 
later  determine  by  a  bacteriological  examination  whether  the  membrane 
is  diphtheritic  or  due  to  diplococci,  streptococci,  staphylococci,  or  other 
microorganisms.  The  bacteriological  examination,  in  fact,  in  these  cases 
is  not  always  to  be  relied  upon.  In  cases  of  simple  rhinitis  I  have  seen  capa- 
ble bacteriologists  demonstrate  bacilli  which  could  not  be  differentiated  from 
diphtheria  bacilli,  and  in  advanced  cases  of  diphtheria  of  the  nose  I  have 
seen  them  fail  to  differentiate  the  specific  microorganism  of  this  disease.  It 
is  wise,  however,  in  every  case  of  severe  rhinitis,  associated  with  marked 
irritation  and  constitutional  symptoms,  to  make  a  bacteriological  examina- 
tion, and  if  diphtheria  bacilli  are  found,  membrane  or  no  membrane, 
antitoxin  should  be  given. 

Prognosis. — The  prognosis  in  the  vast  majority  of  cases  is  good;  the 


414       DISEASES   OF   THE    XASAL   AIUCOI^S   AIEMBRAXE 

disease  runs  a  short  and  l)enign  course  and  terminates  in  recovery.  In 
the  diphtheritic  and  other  pseudomembranous  forms  the  disease  may  ter- 
minate fatally.  The  prognosis  in  these  cases  largely  depends  upon  the 
treatment.  During  the  first  year  of  life  even  simple  rhinitis  may  become  a 
dangerous  disease  which  occasionally  terminates  fatally. 

Chronic  rhinitis,  as  compared  with  its  frequency  in  the  adult,  is  un- 
common in  the  infant  and  young  child.  Chronic  nasal  catarrh  rarely 
supervenes  upon  the  acute  process  except  in  tuberculous  and  syphilitic  chil- 
dren, or  in  those  who  have  chronic  disease  of  the  tonsils  or  adenoids.  A 
relapsing,  or  chronic  coryza  in  an  otherwise  healthy  infant  usually  means 
chronic  disease  of  the  adenoid  tissues  of  the  pharynx. 

Prophylaxis. — As  rhinitis  is  an  air-borne  disease,  due  primarily  to  in- 
fection, and  secondarily  to  causes  which  irritate  the  nasal  mucous  mem- 
brane, the  prophylactic  treatment  consists  in  keeping  the  child  in  fresh  air 
day  and  night.  It  should  live  in  the  open  as  much  as  possible  during  the 
day,  and  sleep  in  a  well-aired  room  at  night.  Well  children  should  be  kept 
away  from  sick  ones.  Infants  and  young  children  should  be  kept  out  of 
closed  street  cars  and  places  of  amusement,  where  large  numbers  of 
people  are  crowded  together  in  a  close,  overheated  atmosphere.  Re- 
curring attacks  of  rhinitis  may  require  the  removal  of  diseased  tonsils  and 
adenoids. 

Treatment. — Children  suffering  from  simple  rhinitis  should  be  kept 
out  of  doors  in  the  fresh  air,  away  from  dusty  streets  and  roads,  that  they 
may  breathe  pure  air,  free  from  germs,  dust,  and  other  irritating  im- 
purities. Living  indoors  and  breathing  warm,  dry,  impure  air  aggra- 
vate the  disease.  Nasal  injections  of  some  mild  alkaline  antiseptic  are 
of  value,  especially  in  older  children;  they  should  be  given  with  a  soft 
all-rubber  syringe,  the  child's  head  being  inclined  forward  with  the  face 
looking  downward,  and  the  fluid  gently  and  slowly  injected  into  the  an- 
terior nares  in  such  a  way  that  the  mucous  membrane  of  the  nose  and 
pharynx  may  be  irrigated.  If  the  child  is  not  old  enough  to  accomplish 
this  operation  without  a  struggle,  it  is  better  not  to  attempt  it  at  all ; 
these  same  antiseptic  applications  may  be  almost  as  effectively  applied 
with  atomizers;  this  is  preferable  to  the  nasal  injections  in  young  chil- 
dren. Inhalations  of  cresolin,  tincture  of  benzoin,  guaiacol  and  oil 
of  turpentine  may  be  used  to  advantage  in  steam  atomizers.  In  every 
case  of  rhinitis,  both  in  infants  and  older  children,  the  following  prescrip- 
tion may  be  instilled  into  the  nose,  four  or  five  drops  three  or  four  times 
a  day :  Oil  of  eucalyptus,  m.  10 ;  menthol,  gr.  l^  to  1 ;  liquid  albolene 
enough  to  make  an  ounce.  This  is  an  effective  remedy,  which  may  be  used 
even  in  the  newborn.  If  in  a  given  case  the  mucous  membrane  of  the 
nose  be  very  raw  and  irritated,  the  menthol  may  for  a  time  be  left  out  of 
the  prescription;  it  is,  however,  an  effective  antiseptic,  and  in  the  dose 
above  given  is  usually  not  irritating.  In  cases  where  there  are  great  irrita- 
tion and  swelling  of  the  mucous  membrane  of  the  nose  the  following  pre- 
scription may  be  used : 


EPISTAXIS  415 

IJ.     Cocain  hydrochlorid gr.  i 

Adrenalin  sol.    (1   to   1,000) 3  i 

Boric  acid   gra  x 

Distilled  water ad  |  i 

From  three  to  five  drops  of  this  mixture  may  be  dropped  into  the  nose 
at  intervals  of  three  or  four  hours.  It  has  a  sedative  action  and  tends  to 
relieve  the  engorgement  of  the  mucous  membrane.  An  ointment  of  lanolin 
containing  1  per  cent,  of  boracie  acid  is  a  soothing  application  to  the  ex- 
ternal nares  and  upper  lip  when  these  parts  are  irritated  and  excoriated. 
This  nuiy  Ije  used  on  pledgets  of  cotton  or  gauze  to  remove  the  crusts 
and  cleanse  the  external  nasal  canal.  In  desperate  cases  in  very  young 
infants  a  small,  soft  catheter  has  been  recommended  for  introduction  along 
the  nasal  canal  to  prevent  its  complete  closure.  In  even  more  desperate 
cases  tracheotomy  has  been  resorted  to  to  save  the  life  of  the  suffocating 
infant.     These  extreme  measures  are  very  rarely  necessary. 

With  the  local  treatment  above  recommended,  a  number  of  drugs  may, 
in  selected  cases,  be  used  internally.  In  older  children  quinin  is  of  de- 
cided advantage,  and  is  to  be  given  in  pill  form,  if  possible.  If  the  child 
be  too  young  for  this,  one  or  two  grains  of  euquinin  may  be  given  at  three 
or  four-hour  intervals.  In  infants  under  eighteen  months  of  age  the  fol- 
lowing prescription  may  be  used: 

Guaiacol  carb grs.  xii 

Salol     grs.  xii 

Sugar     grs.  xii 

Make  12  powders. 

One  every  three  or  four  hours. 

The  treatment  of  chronic  rhinitis  comprehends  the  use  of  all  the  rem- 
edies above  mentioned,  and  in  addition  the  removal  of  the  underlying 
cause.  This  is  usually  some  constitutional  disease  such  as  tuberculosis  or 
syphilis,  or  some  chronic  local  disease  such  as  hypertrophied  adenoids  and 
tonsils.  With  the  removal  of  these  conditions,  chronic  and  recurring 
rhinitis  in  the  child  usually  disappear. 

EPISTAXIS 

Nose-bleed  is  rare  in  young  infants.  It  may  occur  during  the  first 
days  of  life  as  a  symptom  of  syphilis  or  sepsis. 

Etiology. — The  exciting  cause  is  commonly  some  injury  to  the  mucous 
membrane  of  the  nose  produced  by  contusions,  by  foreign  bodies  or  by 
other  traumas.  But  the  direct  exciting  causes,  in  the  majority  of  instances, 
are  of  less  importance  than  the  predisposing  causes,  since  by  them  the 
mucous  membrane  is  put  in  such  a  condition  that  it  bleeds  from  the  slight- 
est injury.  Among  the  predisposing  causes  are  adenoid  vegetations,  nasal 
catarrh  and  ulcerations  of  the  nasal  mucous  membrane.  In  certain  infec- 
tious diseases,  such  as  typhoid  fever,  measles,  influenza,  scarlet  fever  and 
28 


416       DISEASES   OF  THE   NASAL   MUCOUS   MEMBRANE 

whooping-cough,  nasal  hemorrhages  are  common.  They  occur  also  in 
certain  constitutional  diseases,  such  as  hemophilia,  purpura  hemorrhagica, 
peliosis  rheumatica  and  grave  forms  of  anemia,  and  scurvy.  Where  the 
predisposing  causes  are  marked,  nasal  hemorrhages  may  sometimes  be  pro- 
duced by  stooping  and  by  violent  exercise,  or  they  may  be  spontaneous; 
that  is  to  say,  the  exciting  causes  are  not  discoverable. 

Hemorrhages  occurring  from  the  back  part  of  the  nose  may,  especially 
in  infants,  cause  the  blood  to  flow  into  the  pharynx,  where  it  is  swallowed, 
and  produces  a  dark  discoloration  of  fecal  discharges.  Nasal  hemorrhage 
unassociated  with  constitutional  disease  is  rarely  severe  enough  to  pro- 
duce marked  anemia  or  general  weakness.  In  purpura  hemorrhagica, 
severe  toxemia,  and  hemophilia  nose-bleed  may  become  dangerous.  In  the 
majority  of  cases  the  bleeding  point  may  be  located  by  an  examination 
with  a  nasal  speculum. 

Treatment. — In  most  instances  no  treatment  is  required;  the  bleed- 
ing stops  spontaneously  after  a  short  time;  the  home  remedies,  such  as 
swallowing  salt  and  cold  applications  to  the  back  of  the  neck,  occupy  the 
attention  of  the  family  until  the  hemorrhage  ceases.  The  most  effective 
remedy  for  the  relief  of  nasal  hemorrhage  is  the  injection  through  the 
nasal  canal  of  an  adrenalin  solution  after  the  clots  have  been  removed ;  for 
this  purpose  the  1  to  1,000  solution  may  be  diluted  ten  times  and  injected 
through  the  nose  with  a  soft  rubber  syringe;  this  same  solution  may  be 
applied  on  pieces  of  cotton  or  on  strips  of  gauze  which  are  pushed  into  the 
nose  beyond  the  bleeding  point.  Other  remedies  are  rarely,  if  ever,  needed 
for  the  control  of  ordinary  nasal  hemorrhage.  Bleeding  from  the  nose  may 
very  commonly  be  stopped  by  the  simple  introduction  of  pledgets  of  dry  cot- 
ton, without  the  use  of  medicines  to  contract  the  bleeding  vessels.  In  cases 
of  nasal  hemorrhage  associated  with  severe  hemorrhagic  constitutional  dis- 
eases it  may  be  necessary  to  tampon  the  whole  nasal  cavity  with  gauze,  sat- 
urated with  adrenalin  solution.  In  recurring  attacks  of  opistaxis  the  bleed- 
ing point  in  the  nose  may  require  cauterization  in  the  interval  between 
attacks. 

FOREIGN   BODIES   IN    THE    NOSE 

Young  children  very  frequently  push  small  foreign  bodies  into  the 
nose,  such  as  buttons,  grains  of  corn,  beans,  pebbles,  beads,  and  other  small 
objects  with  which  they  play;  thus  lodged  in  the  nostrils  they  often  re- 
main for  days  or  months  before  they  are  discovered.  Foreign  bodies  in 
the  nose  produce  more  or  less  occlusion  of  the  nasal  passage,  and  as  a  re- 
sult a  unilateral  rhinitis  occurs;  this  may  be  severe  enough  to  produce 
a  very  decided  inflammatory  process  with  ulceration.  In  the  great  ma- 
jority of  instances  the  foreign  body  is  discovered  before  it  has  produced 
marked  inflammation,  and  its  removal  from  the  nose  is,  as  a  rule,  a  simple 
process.  If  the  child  be  old  enough  it  may,  by  closing  the  opposite  nos- 
tril, force  the  body  out  by  blowing  the  nose;  in  most  instances  it  can 


DISEASES    OF   TONSILS  417 

readily  be  seen  and  pulled  out  with  a  pair  of  fine  forceps.  If  its  shape 
be  such  that  it  cannot  be  grasped  by  forceps,  it  can  be  removed  by  intro- 
ducing a  small  probe  which  is  bent  very  slightly  at  the  end;  this  may  be 
passed  beyond  and  hooked  over  it.  In  some  instances  it  may  be  neces- 
sary, where  the  swelling  and  inflammation  are  great,  to  relieve  the  sensi- 
tiveness of  the  mucous  membrane  by  the  application  of  cocain.  Where 
the  foreign  body  is  so  far  back  in  the  nasal  passage  that  it  cannot  be  re- 
moved in  one  or  the  other  of  the  ways  described,  it  may  be  pushed  with 
a  small,  cotton-wrapped  probe  back  into  the  pharynx,  being  careful  that 
it  does  not  drop  into  the  larynx  or  trachea. 


CHAPTEE   XLVII 

DISEASES    OF    TONSILS 

The  faucial  tonsils  are  a  part  of  Waldeyer's  lymphatic  ring  which  ex- 
tends around  the  pharynx,  and  includes  the  pharyngeal  tonsil  (adenoids) 
and,  later  in  life,  the  lingual  tonsil.  These  tonsils  are  masses  of  lymphoid 
tissue  which  are  held  together  by  intervening  connective  tissue.  In  the 
infant  and  young  child  the  pharyngeal  tonsil  (adenoids)  is  most  com- 
monly affected  by  disease.  In  childhood  the  faucial  tonsils,  which  are 
comparatively  inactive  during  infancy,  are  very  commonly  diseased,  and 
later  in  life  the  lingual  tonsil  may  be  a  source  of  trouble.  The  faucial  ton- 
sils, whose  function  is  more  or  less  obscure,  are  filled  with  crypts  and  con- 
tain a  large  number  of  mucous  glands.  The  irregularity  of  their  sur- 
face, as  well  as  their  mucous  coating,  enables  them  to  stand  guard  at  the 
entrance  to  the  throat  and  prevent  microorganisms  and  other  disease- 
producing  factors  from  entering  the  pharynx;  the  microorganisms  thus 
picked  up  are  usually  cared  for  in  a  satisfactory  manner  by  the  normal 
tonsil  without  producing  disease.  There  can  be  no  question  but  that  the 
tonsils,  especially  in  children,  serve  an  important  purpose  in  preventing 
contagion.  The  crypts  very  commonly  contain  not  only  mucus  and  par- 
ticles of  food,  but  large  numbers  of  pathogenic  microorganisms,  including 
pneumococci,  diplococci,  streptococci,  staphylococci,  and  bacilli  catarrhalis, 
any  of  which  are  capable  of  setting  up  inflammatory  processes  in  the  mucous 
membrane  of  the  respiratory  passages;  even  when  the  tonsil  itself  becomes 
diseased  or  infected,  the  infection  is  rarely  transmitted  directly  to  internal 
organs.  Jacobi  called  attention  to  the  fact  that  while  Waldeyer's  lymphatic 
ring  is  one  of  the  important  gateways  through  which  infections  of  various 
kinds  enter  the  body,  the  entrance  is  not  effected,  as  a  rule,  directly 
through  the  faucial  tonsils,  but  when  other  portions  of  this  lymphatic 
ring  are  affected,  then  there  is  great  danger  of  the  contagion  obtaining 
entrance  to  the  general  lymph  or  blood  streams,  and  producing  thereby 
general  constitutional  diseases  or  localized  infections  of  internal  organs. 
The  late  Dr.  Frederick  Packard  called  attention  to  the  fact  that  tonsillitis 


418  DISEASES    OF   TONSILS 

very  frequently  preceded  or  was  associated  with  endocarditis,  rheumatism 
and  other  infections.  While  the  normal  tonsil  may  serve  the  important 
purpose  of  protecting  the  infant  from  contagious  diseases  of  various  kinds, 
the  hypertrophied  and  chronically  diseased  tonsil,  harboring  in  its  cr3'pts 
infectious  microorganisms,  frequently  becomes  a  menace  to  the  health  of  the 
child  rather  than  a  ])rotecting  agency  against  disease.  In  such  tonsils  re- 
peated attacks  of  tonsillitis  may  occur  from  slight  predisposing  causes  with- 
out new  infection.  These  are  the  cases  that  are  most  closely  associated  with 
endocarditis,  chorea,  and  acute  rheumatism;  and  with  successive  attacks  of 
ulcerative  tonsillitis  there  may  be  repeated  attacks  of  arthritis,  endocar- 
ditis, or  chorea.  The  lymphoid  ring,  of  which  the  tonsils  are  a  part,  is  in 
close  communication  not  only  with  the  retropharyngeal  lymph  glands,  but 
also  with  the  cervical  lymphatics  situated  below  the  angle  of  the  jaw, 
along  the  lines  of  the  great  vessels  of  the  neck.  In  diseases  of  this  lymphoid 
ring,  therefore,  the  cervical  lymph  nodes  below  the  angle  of  the  jaw  are 
more  or  less  swollen;  the  retropharyngeal  lymph  nodes  are  more  closely 
connected  with  the  pharyngeal  tonsil,  and  the  cervical  lymph  nodes  with 
other  portions  of  this  lymphatic  ring,  including  the  faucial  tonsils.  From 
what  has  been  said,  it  is  evident  that  tonsillitis,  pharyngitis,  and  adenoid 
disease  are  very  commonly  a  part  of  the  same  pathological  process.  In 
the  infant  and  young  child  practically  every  tonsillitis  is  accompanied  by 
more  or  less  pharyngitis,  although  the  reverse  of  this  is  not  true. 

TONSILLITIS 

Acute  Follicular  Tonsillitis. — Etiology. — Acute  follicular  tonsillitis 
is  an  infectious  disease  which  may  be  produced  by  a  number  of  pathogenic 
microorganisms,  chief  among  which  are  diplococci,  streptococci,  staphylo- 
cocci, pneumococci,  micrococci  catarrhalis.  and  influenza  bacilli.  It  not  in- 
frequently occurs  as  an  epidemic,  spreading  through  families,  schools,  and 
institutions  for  children.  It  is  very  commonly  an  important  part  of  the 
syndrome  of  some  of  the  acute  infections,  such  as  scarlet  fever,  influenza, 
rheumatism  and  measles.  Any  of  the  above-named  microorganisms  may  be 
held  for  a  long  time  in  the  tonsillar  crypts,  until  an  exciting  cause  starts 
them  into  activity;  recurring  attacks  of  tonsillitis  are  usually  produced  in 
this  way.  "Catching  cold"  and  traumatism  are  exciting  causes,  which  can 
produce  tonsillitis  only  when  the  contagion  is  present  in  the  tonsillar  crypts. 
In  infants  it  is  also  believed  that  the  fermenting  contents  of  a  disordered 
stomach  may  be  the  exciting  cause.  On  the  other  hand,  there  can  be  no 
question  but  that  gastrointestinal  indigestion  and  infection  are  very  com- 
monly secondary  to  tonsillitis,  the  infected  mucus  when  swallowed  being 
the  exciting  cause. 

Certain  constitutional  diseases,  such  as  tuberculosis,  the  honphatic 
diathesis,  rheumatism,  and  gout,  may  predispose  to  tonsillitis. 

Symptomatology. — In  the  infant  and  young  child,  not  able  to  locate 
its  pain,  or  point  out  the  site  of  the  disease,  tonsillitis  may  be  overlooked, 


TONSILLITIS  419 

unless  the  physician  adopts  the  rule  of  carefully  inspecting  the  throat  of 
every  sick  child.  It  usually  announces  itself  with  fever,  pain,  general  dis- 
comfort, and  in  sonie  instances  with  more  or  less  marked  prostration. 
The  fever  may  rise  as  high  as  103°  or  104° F.,  and  usually  lasts  from  two 
to  four  days;  during  this  time  there  may  be  marked  irregularities  of  the 
temperature.  Tliere  is  nothing  specific  in  the  temperature  curve,  but  it  is 
im])ortant  to  remember  that  more  or  less  fever  is  a  symptom  of  every  case 
of  tonsillitis,  and  that  if  it  lasts  longer  than  five  or  six  days  there  is  prob- 
ably some  complication,  such  as  otitis  media,  suppuration  of  lymph  glands, 
or  the  spread  of  the  inflammation  from  the  tonsils  to  some  other  portion  of 
the  res])iratory  passages.  The  fever  is  accompanied  by  malaise,  headache, 
backache,  and  sometimes  is  associated  with  a  chill;  chilly  sensations  are 
very  common  in  older  children.  Young  infants  take  their  food  badly, 
nurse  with  difficulty,  and  their  breathing  may  be  more  or  less  obstructed, 
especially  during  sleep.  Older  children  may  complain  of  sore  throat  and 
pain  in  swallowing;  the  lymph  nodes  at  the  angle  of  the  jaw  are  enlarged. 

The  diagnosis  is  made  by  an  inspection  of  the  throat.  The  tonsils  are 
red  and  swollen;  the  neighboring  mucous  membranes  of  the  pharynx  and 
pillars  of  the  soft  palate  may  also  be  inflamed,  and  all  of  these  tissues 
may  be  covered  with  a  mucopurulent  discharge.  In  almost  every  case  of 
tonsillitis  not  only  the  parenchyma,  but  the  glandular  structures  of  the 
mucous  membran©5  are  involved,  and  sooner  or  later  small  grayish-white 
spots  are  to  be  seen  scattered  over  both  tonsils;  these  may  enlarge,  run 
together,  and  form  irregular,  grayish-yellow  patches,  which  are  thin,  and 
cling  lightly  to  the  tonsillar  tissue,  filling  the  crypts  and  in  some  instances 
covering  the  greater  portion  of  the  tonsillar  mucous  membrane.  Between 
the  membranous  deposits,  however,  strips  and  patches  of  swollen  and  red 
mucous  membrane  may  usually  be  seen.  More  rarely  a  pseudomembrane, 
croupous.  ])ut  non-diphtheritic  in  character,  may  form. 

Triceromembranous  Tonsillitis. — Ulceromembranous  tonsillitis,  or  Vin- 
cent's angina,  is  a  form  of  tonsillitis  produced  by  the  symbiotic  action 
of  Vincent's  bacillus  and  spirillum.  The  bacillus  is  fusiform  in  shape, 
shows  transverse  markings,  has  pointed  ends,  and  is  much  longer  than 
the  diphtheria  bacillus.  The  spirillum  is  slender  and  usually  has  three 
or  four  whorls.  Vincent's  angina  is  much  less  common,  runs  a  milder 
course  and  has  fewer  constitutional  symptoms  than  ordinary  follicular 
tonsillitis;  it  not  infrequently  involves  only  one  tonsil.  The  diagnosis  is 
made  by  finding  the  microorganisms,  which  are  readily  detected  in  smear 
preparations,  and  by  the  presence  of  a  grayish-yellow  ulcer  on  one  or  both 
tonsils,  which  usually  varies  from  one-fourth  to  one-half  inch  in  diameter, 
l)ut  may  cover  the  whole  tonsil.  This  form  of  tonsillitis  may  be  associated 
with  a  membranous  stomatitis  of  the  same  character. 

Cause  and  Prognosis. — Follicular  tonsillitis  usually  runs  its  course 
in  from  three  to  five  days.  Following  the  acute  symptoms,  there  may 
be  a  rather  slow  convalescence  covering  a  week  or  ten  days,  during  which 
time  the  patient  recovers  his  appetite  and  strength,  and  the  tonsils  grad- 


420  DISEASES   OF   TOXSILS 

ually  diminish  in  size  and  resume  their  normal  color  and  appearance.  In 
Vincent's  angina  the  disease  runs  a  longer  course,  and  convalescence  is 
delayed. 

The  prognosis  in  all  forms  of  acute  tonsillitis  is  good;  the  great  ma- 
jority of  these  cases  recover  without  complications.  It  should  be  remem- 
bered, however,  that  otitis  media,  peritonsillitis,  chorea,  endocarditis,  and 
septic  arthritis  are  dangerous  complications  which  may  possibly  occur.  The 
danger  from  these  complications,  as  previously  noted,  is  much  greater  in 
the  frequently  recurring  attacks  of  acute  follicular  tonsillitis  associated  with 
chronic  tonsillar  hypertrophy. 

Differential  Diagnosis. — With  the  onset  of  every  tonsillitis,  the  physi- 
cian should  be  on  the  lookout  for  influenza,  scarlet  fever,  and  diphtheria. 
From  influenza  and  scarlet  fever  acute  tonsillitis  is  differentiated  by  the 
general  symptom-complex  of  these  diseases.  From  diphtheria,  however, 
it  is  practically  impossible  in  many  cases  to  make  a  differential  diagnosis, 
except  by  a  bacteriological  examination.  In  all  cases  of  tonsillitis  which 
clinically  resemble  diphtheria  it  is  wise  to  give  a  dose  of  antitoxin  with- 
out waiting  for  the  bacteriological  examination  to  determine  the  presence 
or  absence  of  Klebs-Loffler  bacilli.  In  the  great  majority  of  cases  the 
pictures  presented  by  true  tonsillar  diphtheria  and  acute  follicular  ton- 
sillitis are  fairly  distinct.  In  diphtheria  the  exudation  presents  the  ap- 
pearance of  a  membrane  covering  all  or  part  of  the  ulcerated  tonsil ;  it  is 
dark  gray  in  color,  and  so  closely  attached  that  any  effort  at  its  renloval 
produces  bleeding.  In  addition  to  the  large  membranous  patch  small 
patches  similar  in  character  may  be  seen  on  the  uvula  or  pharynx.  This 
picture  is  very  different  from  the  widely  disseminated,  grayish-white,  small 
patches  seen  in  follicular  tonsillitis,  and  even  when  these  enlarge  and 
coalesce  to  form  larger  patches  of  membrane  the  exudate  thus  formed  is 
rather  loosely  adherent,  and,  as  a  rule,  easily  removed  without  producing 
hemorrhage.  The  differential  diagnosis  in  difficult  cases  must  be  made 
first  by  the  response  of  the  disease  to  antitoxin,  and  second  by  a  bac- 
teriological examination  of  the  throat. 

CHRONIC    TONSILLAR   HYPERTROPHY 

This  is  the  condition  previously  referred  to  of  chronically  enlarged  and 
diseased  tonsils,  so  frequently  seen  in  children  who  have  suffered  from 
repeated  attacks  of  tonsillitis.  It  is  commonly  associated  with  chronic 
disease  of  the  adenoids  and  with  more  or  less  chronic  hypertrophy  of 
the  entire  lymphoid  ring  of  the  pharynx.  A  small  percentage  of  these 
cases  is  due  to  the  tubercle  bacillus. 

Symptomatologfy. — Patients  suffering  from  chronic  tonsillar  hyper- 
trophy commonly  lack  strength,  are  malnourished,  anemic,  and  have  poor 
chest  development.  They  are  restless,  nervous,  sleep  poorly  and  commonly 
speak  with  an  altered  nasal  tone,  and  many  are  mouth-breathers  from 
complicating  adenoids.     The  lymphatic  glands  at  the  angle  of  the  jaw 


PEEITONSILLAK    ABSCESS  421 

are  chronically  enlarged.  The  diagnosis  is  made  by  an  examination  of 
the  throat.  The  tonsils  are  enlarged  and  covered  with  irregular  deep 
crypts,  in  which  not  infrequently  caseous  material  accumulates,  presenting 
the  appearance  of  isolated  white  patches.  In  such. '4ae(BSvthe  breath  is  offen- 
sive and  the  caseous  material,  when  removed  by  a  dull  instrument,  has  the 
same  bad  odor.  These  are  the  cases  in  which  the  tonsils  no  longer  act  as 
safeguards  against  infection,  but  are  an  actual  menace  to  the  health  of 
the  child,  subjecting  it  to  the  dangers  of  tonsillitis,  middle-ear  infection, 
endocarditis,  arthritis,  diphtheria,  scarlet  fever,  and  other  infections. 
There  is  little  doubt  but  that  in  many  of  these  cases  in  which  there  is 
great  chronic  enlargement  of  the  tonsils  this  condition  acts  injuriously 
upon  the  health  of  the  child  by  mechanically  interfering  with  the  respira- 
tion and  producing  a  low  form  of  chronic  toxemia.  Chronic  tonsillar 
hypertrophy  may  be  a  symptom  of  the  lymphatic  diathesis;  in  such  cases, 
like  the  anemia,  malnutrition,  and  lack  of  development,  it  is  an  expression 
of  a  general  constitutional  disorder. 

PERITONSILLAR   ABSCESS 

Peritonsillar  abscess,  or  quinsy,  is  comparatively  rare  in  infancy  and 
young  childhood.  The  microorganisms  producing  this  abscess  are  ap- 
parently the  same  varieties  of  streptococci  and  staphylococci  found  in 
ordinary  tonsillitis,  and  yet  the  disease  not  infrequently  occurs  in  epi- 
demic form.  That  is  to  say,  in  certain  epidemics  of  tonsillitis,  quinsy 
may  be  common;  in  others  it  may  be  a  rare  occurrence.  Individuals  who 
have  had  one  attack  of  quinsy  are  much  more  liable  to  second  and  third 
attacks.  The  disease  usually  occurs  on  one  side;  it  may,  however,  be 
bilateral. 

Symptomatology. — Fever,  chilly  sensations  and  a  painful  sore  throat 
mark  the  onset  of  quinsy.  The  pain  becomes  very  severe,  is  throbbing 
in  character,  and  is  very  much  aggravated  by  swallowing  and  talking. 
There  is  great  tenderness  and  more  or  less  swelling  and  tumefaction  be- 
neath the  angle  of  the  jaw  in  the  region  of  the  tonsil.  Difficulty  is  ex- 
perienced in  opening  the  mouth. 

Diagpiosis. — The  diagnosis  is  made  largely  upon  the  fact  that  the  pain 
is  out  of  all  proportion  to  the  appearance  of  the  throat  on  examination. 
The  follicular  tonsillitis,  which  may  have  been  present  in  the  beginning, 
has  entirely  disappeared,  but  the  tonsil,  and  especially  the  supra-tonsillar 
tissue,  remains  red  and  edematous,  and  on  examination  with  the  finger, 
fluctuation  may  be  found.  The  abscess  continues  to  increase  in  size,  and 
if  not  opened  breaks  spontaneously  after  several  days,  and  discharges  into 
the  throat  a  quantity  of  pus,  more  or  less  tinged  with  blood.  The  relief 
which  follows  the  evacuation  of  the  pus  is  very  great,  and  convalescence 
is  usually  rapidly  established. 


422  DISEASES    OF   TOXSILS 


TREATMENT   OF   DISEASES    OF    THE    TONSILS 

Treatment  of  Follicular  Tonsillitis.  — With  the  onset  of  acute  symptoms 
the  child  should  be  put  to  bed  and  isolated.  A  liquid  diet  suitable  to  its 
age  should  be  selected,  not  only  with  reference  to  protecting  it  from  gas- 
trointestinal complications,  but  also  with  the  idea  of  throwing  as  little 
work  upon  the  excretory  organs  as  possible.  A  milk  and  cereal  diet  is 
to  be  recommended  at  the  onset,  until  it  is  definitely  determined  that  the 
tonsillitis  is  not  the  beginning  of  scarlet  fever,  diphtheria,  influenza,  or 
some  other  acute  infection.  When  it  has  been  decided  that  only  a  simple 
follicular  tonsillitis  is  present,  the  diet  in  older  children  may  be  increased 
to  suit  the  demands  of  the  child.  In  most  instances  the  difficulty  in  swal- 
lowing causes  the  child  to  refuse  food.  In  older  children  ice-cream,  thick 
gruels,  milk-toast,  and  soft,  semi-solid  food  are  more  grateful  and  more 
easily  taken  than  milk  alone.  The  rest-in-bed  treatment  should  be  contin- 
ued as  long  as  the  child  has  fever  and  marked  throat  symptoms.  In  every 
case  the  physician  should  carefully  examine  the  heart  in  anticipation  of 
the  possible  development  of  acute  endocarditis,  and  frequent  urinah'ses 
should  be  made,  as  albuminuria  may  occur. 

Medical. — The  medical  treatment  consists  in  giving  quinin,  sodium 
salicylate,  aspirin,  phenacetin,  or  salol.  Quinin  is  a  valuable  remedy  and 
should  be  given  to  all  children  who  are  old  enough  to  take  pills  or  capsules. 
In  younger  children,  and  especially  in  infants,  quinin,  because  of  its 
taste,  is  contraindicated.  The  struggle  to  give  an  infant  quinin  in  liquid 
form  may  not  only  produce  great  nervous  excitement,  but  may  upset  its 
stomach  and  cause  it  to  refuse  food  and  other  medication.  Salicylate  of 
soda  from  oil  of  wintergreen  is  a  valuable  remedy  in  older  children.  It 
may  be  given  in  capsule  combined  with  the  quinin,  or  in  solution  put  up 
with  glycerin  and  peppermint  water.  For  a  child  from  six  to  ten  years 
of  age,  two  grains  of  quinin  and  three  grains  of  salicylate  of  soda  may  be 
given  every  four  to  six  hours.  In  younger  children  aspirin  is  a  valuable 
remedy;  it  may  be  given,  combined  with  sugar,  in  one-grain  powders  to 
a  child  two  years  of  age;  this  dose  may  be  repeated  at  three-hour  inter- 
vals. One  grain  of  phenacetin,  one  or  two  grains  of  salol,  and  one  grain 
of  sugar  may  be  given  as  a  powder  to  infants  between  the  ages  of  one  and 
two.  This  prescription  is  effective  in  protecting  the  gastrointestinal 
canal,  reducing  the  temperature,  relieving  the  nervous  irritability,  and 
making  the  infant  altogether  more  comfortable.  The  above  remedies  are 
to  be  used  during  the  acute  stage  of  the  disease,  which  lasts  but  two  or 
three  days;  the  aspirin,  and  especially  the  sodium  salicylate,  may  be  given, 
however,  for  a  longer  time  to  older  children  in  whom  there  is  a  clear  family 
history  of  gout  or  rheumatism.  At  the  very  onset  of  the  disease  the  infant 
or  child  should  be  given  calomel  in  small  doses  until  one  or  two  grains 
have  been  taken.  This  is  to  be  followed  by  a  dose  of  castor-oil,  or  saline 
laxative;  the  castor-oil  is  preferable.     On  the  third  or  fourth  day  of  the 


TREATMENT    OF    DISEASES    OF    THE    TONSILS       423 

treatment  a  second  dose  of  castor-oil  should  be  given ;  the  oil  serves  the 
purpose  of  clearing  the  intestinal  canal  and  preventing  gastrointestinal 
complications;  the  germ-laden  mucus,  which  is  swallowed,  can  in  no 
manner  be  so  satisfactorily  carried  off.  The  care  of  the  intestinal  canal  is 
especially  important  in  the  treatment  of  tonsillitis  in  infants  under  two 
years  of  age ;  this  applies  with  equal  force  to  the  treatment  of  all  catarrhal 
conditions  of  the  respiratory  passages.  Intestinal  infection  and  gastro- 
enteritis are  not  only  troublesome,  but  dangerous  complications,  much 
more  serious  than  the  tonsillitis  which  produced  them.  Infants,  tliere- 
fore,  suffering  from  tonsillitis  should  have  their  milk  formulas  reduced, 
and  if  diarrhea  appears  it  should  be  treated  by  diet  and  proper 
medication. 

Local  Treatment. — In  the  majority  of  instances  relief  and  benefit 
follow  the  application  of  cold  to  the  neck.  This  may  be  applied  in  the 
form  of  cloths  wrung  out  of  ice-water,  or  by  a  small  ice-bag  wrapped  in 
a  towel,  and  placed  under  the  angle  of  the  jaw  over  the  tonsillar  region. 
Cold  applications  are  of  special  value  when  the  lymphatics  at  the  angle  of 
the  jaw  are  enlarged,  when  there  is  a  throbbing  sensation  in  the  throat 
with  marked  tenderness  externally  over  the  tonsils,  and  in  individuals 
who  have  had  repeated  attacks  of  quinsy ;  the  early  application  of  cold 
may  in  these  cases  prevent  the  formation  of  a  peritonsillar  abscess.  In 
some  cases  very  hot  applications  applied  to  the  neck  give  more  relief  than 
cold ;  in  younger  children  and  infants  the  hot  applications  are,  as  a  rule, 
preferable.  Older  children  should  gargle,  or  use  a  spray  of  peroxid  of 
hydrogen,  diluted  two  or  three  times  with  water;  this  is  indicated  for 
twenty-four  or  thirty-six  hours  only.  It  is  an  excellent  throat  antiseptic, 
but  if  continued  too  long,  as  Jacobi  long  ago  pointed  out,  irritates  the 
mucous  membrane.  As  the  white  patches  disappear  on  the  second  or  third 
day,  the  peroxid  of  hydrogen  solution  is  to  be  changed  for  some  mild  al- 
kaline antiseptic,  which  may  also  be  used  as  a  gargle,  or  with  an  atomizer, 
so  as  to  thoroughly  cleanse  the  throat  and  pharynx  of  the  mucopurulent 
discharge  which  is  present.  These  alkaline  antiseptic  solutions  may  be 
made  by  adding  boracic  acid  to  a  physiological  salt  solution,  or  by  using 
some  of  the  alkaline  antiseptic  tablets  now  on  the  market.  It  may  be 
necessary  to  paint  the  throat  or  use  stronger  or  more  astringent  gargles 
and  spravs.  A  weak  solution  of  the  tincture  of  chlorid  of  iron,  one 
to  four  or  five  parts,  may  be  used  for  painting  the  tonsil  during  conval- 
escence. Weak  iodin  and  silver  (argyrol)  solutions  may  also  be  used  for 
swabbing  the  tonsil,  but  on  the  whole  these  stronger  applications  are  rare- 
ly indicated  in  the  convalescence  from  acute  tonsillitis.  They  are  of  more 
value  in  the  subacute  or  chronic  forms  of  tonsillar  hypertrophy. 

Infants  and  children  suffering  from  tonsillitis  are  made  more  com- 
fortable by  sponge  and  tub  baths,  which  relieve  the  nervousness  and  reduce 
the  temperature.  During  convalescence  older  children  are  benefited  by 
such  tonics  as  fresh  air,  good  food,  and  the  malt  and  iron  preparations. 
The  tincture  of  chlorid  of  iron  and  the  syrup  of  iodid  of  iron  are  old 


424  DISEASES   OF  THE  PHARYNX 

and  time-honored  remedies  of  value  in  these  cases.  They  may  be  given 
after  meals  in  three  to  five-drop  doses  diluted  with  glycerin  and  water. 

Treatment  of  Vincent's  Angina.— The  treatment  of  Vincent's  angina 
consists  chiefly  in  the  careful  local  application  of  caustics  to  the  ulcerated 
area,  such  as  strong  nitrate  of  silver  solutions  and  chromic  acid. 

Treatment  of  Peritonsillar  Abscess. — Peritonsillar  abscess,  or  quinsy, 
should  be  treated  by  opening  the  abscess  with  a  guarded  bistoury,  and  the 
throat,  for  a  number  of  days  following  the  incision,  should  be  disinfected 
by  some  of  the  alkaline  antiseptics  above  mentioned. 

Treatment  of  Chronic  Tonsillar  Hypertrophy. — Tlie  treatment  of 
chronic  tonsillar  hypertrophy  falls  within  the  domain  of  the  throat  spe- 
cialist, rather  than  the  general  practitioner.  The  guillotine  in  the  hands 
of  an  inexperienced  operator  may  remove  the  greater  part  of  the  tonsils 
and  give  relief  for  a  number  of  years,  but  if  tonsillar  tissue  be  left  there 
will  be  in  most  instances  a  gradual  return  of  the  tonsillar  tumor,  and  a 
second  operation  some  years  later  may  be  necessary.  For  this  reason  the 
radical  operation  of  enucleating  the  entire  tonsil  within  its  capsule  is 
much  to  be  preferred.  Adenoids  and  other  hypertrophied  lymphoid  tissues 
of  the  lymphoid  ring  of  the  pharynx  should  always  be  removed  at  the  same 
time;  this  is  a  slight  operation,  which  should  follow  the  removal  of  the 
tonsils.  It  may  be  well  also  to  note  that  a  white,  innocuous  membrane, 
somewhat  resembling  diphtheria,  forms  over  the  wound  produced  by  re- 
moving the  tonsil. 


CHAPTER    XLVIII 

DISEASES    OF    THE    PHARYNX 

ADENOIDS 

In  1868  Dr.  William  Meyer,  of  Copenhagen,  called  the  attention  of 
the  medical  world  to  the  hypertrophy  and  disease  of  the  lymphoid  tissue, 
which  so  commonly  occur  in  the  vault  and  posterior  and  lateral  walls  of 
the  nasopharynx.  This  lymphoid  tissue  is  spoken  of  as  Luschka's  tonsil, 
or  the  pharyngeal  tonsil,  and  the  hypertrophy  is  commonly  spoken  of  as 
adenoid  growths.  Other  portions  of  the  pharyngeal  wall,  however,  no- 
tably its  posterior  surface,  are  rich  in  lymphoid  tissue,  and  these  lymphoid 
follicles  are  commonly  markedly  enlarged  when  there  is  any  great  increase 
in  the  size  of  the  pharyngeal  tonsil.  These  enlarged  follicles,  therefore, 
which  may  be  readily  seen  on  the  posterior  wall  of  the  pharynx,  are  an 
important  indication  of  the  presence  of  adenoid  growths.  The  faucial 
tonsils  are  also  commonly  diseased  and  hypertrophied  in  the  presence  of 
marked  adenoid  disease;  this,  however,  is  not  always  so,  since  extensive 
adenoid  growths,  almost  filling  the  vault  of  the  nasopharynx,  may  be  pres- 
ent with  little  or  no  disease  of  the  tonsils ;  this  is  more  commonly  seen  un- 


ADENOIDS  425 

der  three  years  of  age.  In  adenoid  growths  the  orifices  of  tlie  Eustachian 
tubes  are  not  infrequently  surrounded  by  diseased  adenoid  tissue. 

Frequency. — Much  difference  of  opinion  still  exists  as  to  the  frequency 
of  this  disease.  It  has  been  variously  estimated  that  from  10  to  35  per 
cent,  of  all  school  children  between  the  ages  of  six  and  ten,  living  in  cold, 
damp  climates,  such  as  are  found  in  our  middle  and  northern  states,  have 
sufficient  adenoid  disease  to  demand  operative  interference.  It  should  be 
remembered  that  the  pharyngeal  tonsil  is  normal  tissue,  and  that  a  mod- 
erate amount  of  hypertrophy  may  exist  without  producing  either  local  or 
constitutional  injury.  The  question,  therefore,  for  the  physician  to  decide 
is  not  whether  the  child  has  adenoids,  but  whether  the  adenoids  are  suffi- 
ciently enlarged  or  diseased  to  produce  either  a  local  or  constitutional 
disturbance  which  injures  its  health. 

Etiology.^ — Adenoids  are  especially  common  between  the  ages  of  four 
and  ten,  but  they  are  not  infrequent  during  the  first  year  of  life  and  may 
be  congenital.  Heredity,  the  lymphatic  diathesis,  glandular  tuberculosis, 
and  cold,  damp  climates  are  classed  among  the  predisposing  causes,  but 
the  real  cause  of  the  disease  is  infection.  The  adenoid  tissue  becomes  more 
and  more  hypertrophied  with  repeated  infections,  and  in  its  folds  the 
microorganisms,  capable  of  producing  acute  inflammation,  are  held  from 
one  acute  attack  to  another.  All  the  etiological  factors  of  rhinitis  become 
the  etiological  factors  of  adenoid  growths,  since  repeated  attacks  of  coryza 
are  almost  constantly  associated  with  hypertrophy  of  this  lymphoid  tissue. 
Colds  in  the  head,  ordinary  epidemic  grippe,  true  influenza,  measles, 
and  all  the  acute  infections  capable  of  producing  catarrhal  disease  of  the 
mucous  membrane  of  the  nose  and  pharynx  may  be  etiologically  related  to 
adenoid  growths. 

Symptomatology. — The  symptoms  vary  greatly  with  the  extent  of  the 
hypertrophy  of  the  lymphoid  tissue,  with  the  severity  of  the  inflammation, 
and  with  the  associated  complications.  The  most  characteristic  symptoms 
are  recurring  attacks  of  rhinitis,  tonsillitis,  pharyngitis,  and  lar^'ngitis, 
with  snoring  and  mouth  breathing  in  the  intervals  between  these  attacks. 
Sleeping  and  waking,  the  child's  mouth  is  partially  open;  this  is  due  to 
partial  nasal  obstruction.  The  voice  is  thick,  muffled,  and  frequently  has 
a  nasal  twang.  Earache  and  partial  deafness  are  common.  Otitis  media 
may  occur.  An  unexplained  running  of  the  ear,  which  fails  to  yield  to 
ordinary  treatment  and  which  is  associated  with  recurring  attacks  of 
pharyngitis,  is  almost  always  due  to  adenoid  growths.  Eecurring  attacks 
of  epistaxis  are  not  infrequent.  Laryngitis  and  bronchitis  very  frequently 
follow  the  acute  pharyngitis,  which  is  from  time  to  time  lighted  up  by 
chronic  adenoid  disease.  The  nervous  symptoms  associated  with  adenoid 
disease  vary  greatly.  In  aggravated  cases  the  child  may  suffer  from  sleep- 
lessness, general  nervous  irritability,  headache,  night-terrors,  and  incon- 
tinence of  urine.  There  can  be  no  question  but  that  pronounced  adenoid 
growths,  occurring  in  malnourished  and  neurotic  children,  may  produce 
very  pronounced  reflex  neuroses.     In  such  cases    I  have  frequently  seen 


426  DISEASES   OF   THE   PHAKYXX 

night-terrors  and  incontinence  of  urine  disappear  when  the  adenoids  were 
removed.  An  enlarged  chain  of  lymph  nodes  behind  the  sternocleidomastoid 
muscle,  when  associated  with  the  catarrhal  symptoms  above  described,  is 
strongly  confirmatory  of  adenoid  growths.  In  marked  cases  of  adenoid 
disease  which  have  existed  for  a  long  time,  the  facial  expression  of  the 
child  may  strongly  suggest  the  condition.  He  has  a  stupid,  vacant  look, 
his  mouth  is  open,  the  bridge  of  his  nose  is  flat,  his  upper  lip  appears 
thick,  the  nasolabial  fold  is  obliterated,  and  his  lower  jaw  protrudes  in 
such  a  manner  as  to  give  the  appearance  of  a  long  face  which  narrows 
toward  the  chin.  The  hard  palate  may  show  a  very  high  arch  and  the 
upper  teeth  may  be  displaced.  Not  infrequently  these  children  have  nar- 
row, poorly  developed  chests,  and  are  below  par  in  their  physical  devel- 
opment. They  also  have  the  appearance  of  being  below  normal  in  their 
mental  development;  this,  however,  is  perhaps  largely  due  to  their  stupid 
expression  and  to  the  fact  that  because  of  partial  deafness,  or  their  fre- 
quent attacks  of  illness,  they  have  not  had  mental  training  in  keeping 
with  their  age.  The  mental  deficiency  in  these  cases  is  not  real,  but 
merely  apparent,  and  disappears  quickly  with  the  removal  of  the  adenoids 
and  the  improvement  of  the  child's  general  physical  condition.  In  young 
infants  the  nasal  occlusion  caused  by  adenoid  disease  interferes  with  nurs- 
ing. As  the  infant  sleeps,  its  mouth  and  pharynx  become  dry,  and  it 
not  infrequently  awakens  with  a  choking  cry  and  for  a  time  may  have 
difficulty  in  getting  its  breath.  These  symptoms  are  more  commonly 
due  to  the  associated  rhinitis  than  to  the  adenoid  disease. 

Diagnosis. — The  diagnosis  of  adenoids  may  be  suspected  or  even  made 
from  the  above  symptom  group,  but  the  extent  of  the  disease  and  fre- 
quently its  existence  can  only  be  definitely  determined  by  digital  ex- 
amination of  the  nasopharynx.  For  this  examination  the  physician  stands 
behind  the  patient  and  holds  the  child's  head  firmly  with  his  left  arm; 
the  finger  of  his  right  hand  is  quickly  introduced  back  of  the  soft  palate, 
high  up  into  the  nasopharynx ;  there  the  location,  the  extent,  and  the  char- 
acter of  the  adenoid  mass  may  be  felt.  The  adenoid  tissue  is  usually  soft 
and  friable;  the  examining  finger  therefore  comes  away  bloody.  In 
other  instances,  small,  hard  adenoid  masses  are  located,  which  do  not 
break  down  readily.  During  this  examination,  which  requires  but  a  few 
seconds,  the  child's  mouth  is  to  be  held  open  with  a  mouth-gag,  or  with 
the  fingers  of  the  left  hand,  pushing  in  the  cheek  between  the  molar  teeth, 
otherwise  the  finger  of  the  right  hand,  which  is  making  the  examination, 
may  be  bitten  or  otherwise  injured. 

Treatment. — The  medical  treatment  of  acute  adenoid  inflammation 
is  in  every  way  similar  to  the  treatment  of  rhinitis,  which  has  been  already 
given  in  detail.  The  treatment  of  acute  catarrhal  inflammations  of  the 
tonsils,  larynx,  and  bronchial  tubes,  which  are  frequently  associated  with 
adenoid  disease,  is  given  in  the  treatment  of  these  conditions.  There  is 
in  fact  no  medical  treatment  which  has  more  than  a  palliative  influence. 
The   treatment   of    adenoid    growths    is    essentially    surgical,    and    when 


EETROPHABYNGEAL   ABSCESS 


437 


operative  interference  is  necessary  these  cases  should  be  referred  to  a 
specialist.  The  removal  of  these  growths  is  not  a  difficult  operation,  but  is 
one  requiring  a  certain 
amount  of  experience 
and  skill,  and  this  is 
especially  true  since 
very  commonly  in  con- 
nection with  the  re- 
moval of  adenoids  it  is 
advisable  to  remove  the 
tonsils.  In  very  young 
children  it  is  better  to 
remove  the  adenoid  tis- 
sue alone  unless  the 
tonsils  be  markedly  hy- 
pertrophied  and  dis- 
eased. This  can  be  done 
without  an  anesthetic. 
Indications  for 
Surgical  Treatment. 
— Adenoids  should  be 
removed  in  all  cases 
where  either  by  local  ir- 
ritation or  general  con- 
stitutional disturbance 
they  interfere  with  the 
health    of    the     child; 

when  the  middle  ear  has  been  involved;  when  associated  with  recurring 
attacks  of  rhinitis  and  tonsillitis;  when  pronounced  neurotic  disorders  are 
present,  and  when  the  nasal  obstruction  is  such  as  to  produce  mouth  breath- 
ing. In  addition  to  this,  large  adenoid  growths  filling  the  vault  of  the  naso- 
pharynx should  be  removed  whether  or  not  they  produce  local  or  other 
symptoms. 

RETROPHARYNGEAL   ABSCESS 

The  comparative  frequency  of  this  condition  in  infancy  is  due  to  the 
abundant  distribution  and  marked  functional  activity  of  lymph  nodes  and 
their  connecting  vessels  in  the  pharyngeal  wall  at  this  age.  The  dimin- 
ishing frequency  after  the  second  year  of  life  is  believed  to  be  due  to  the 
gradual  disappearance  and  diminished  functional  activity  of  the  lym- 
phatics in  the  posterior  and  lateral  walls  of  the  pharynx  during  early 
childhood.  Infection  of  these  lymph  nodes,  and  the  consequent  develop- 
ment of  a  retropharyngeal  abscess,  occurs  more  readily  because  of  the 
close  communication  of  the  pharyngeal  lymphatics  with  those  of  the  naso- 
pharynx.   The  pus-forming  cocci  and  the  influenza  bacillus  are  the  common 


Fig.  67. — Position 


IN     Examination 
Growths. 


FOB     Adenoid 


428 


DISEASES   OF  THE  PHAEYNX 


exciting  causes.  Koplik  found  streptococci  in  all  of  his  cases.  Infection 
is  commonly  secondary  to  ulcerative  or  catarrhal  inflammation  of  some 
part  of  the  throat  or  nasopharynx;  adenoid  inflammation,  tonsillitis,  or 
pharyngitis  usually  precede  the  retropharyngeal  abscess.  Influenza,  scarlet 
fever,  diphtheria,  and  the  various  acute  infections  which  produce  ca- 
tarrhal disease  of  the  respiratory  passages  may  be  exciting  causes.  Gland- 
ular tuberculosis,  rickets,  and  other  constitutional  diseases,  which  pro- 
duce malnutrition,  may  be  predisposing  factors.  Age  is  the  most  notable 
predisposing  cause.  Bokay  records  467  cases  of  which  296  occurred  during 
the  first  year  of  life,  and  thereafter  the  disease  occurred  with  gradually 
diminishing  frequency,  being  very  rare  after  the  fifth  year.  These  statis- 
tics, which  are  in  accord  with  those  of  Koplik  and  other  observers,  show 
the  comparative  infrequency  of  this  disease  after  the  first  year  of  life. 

Symptomatology. — The  symptoms  are  frequently  obscured  in  the  be- 
ginning by  the  causative  infection.  As  these  subside  the  characteristic 
syndrome  produced  by  a  retropharyngeal  abscess  begins  to  make  its  ap- 
pearance. The  type  of  temperature  changes  and  becomes  septic  in  char- 
acter, with  marked  remissions  and  perhaps  intermissions.    The  obstruction 

caused  by  the  swelling 
in  the  pharyngeal  wall 
causes  the  infant  to  re- 
ject its  food;  it  lets  go 
both  the  breast  and  the 
nipple  to  get  its  ])reath. 
W^ien  asleep  the  infant 
snores,  and  may  awaken 
with  marked  difficulty 
in  breathing,  in  bad 
•"•■  cases  gasping  for  air. 
Not  infrequently  a 
hoarse  cough  is  an  ag- 

FiG.  68.— Retropharyngeal  Abscess.  (Poirier  and  Charpy.)  gravatmg  symptom,  but 

it  has  not  the  barking, 
characteristic  hoarse  sound  of  either  spasmodic  or  true  croup.  The  pharyn- 
geal stridor  continues  when  the  child  is  awake.  The  head  usually  is  held 
rigidly  and  often  inclined  toward  one  side,  and  the  infant  cries  when  the 
neck  is  bent  from  this  position.  The  lymph  nodes  at  the  angle  of  the  jaw 
are  enlarged. 

The  above  clinical  picture  can  scarcely  be  mistaken  for  anything  ex- 
cept laryngeal  stenosis,  and  there  should  really  be  no  difficulty  in  making 
the  diagnosis  between  these  two  conditions.  The  fluctuating  temperature 
and  the  absence  of  the  characteristic  croupy  cough  should  exclude  both 
spasmodic  and  true  croup.  Finally  an  examination  of  the  pharj^nx  of  the 
child  reveals  the  tense  fluctuating  tumor  on  the  postero-lateral  pharyngeal 
wall;  this  tumor,  from  one-half  to  one  inch  in  diameter,  may  sometimes 
be  seen  by  using  a  tongue  depressor,  or  it  may  be  felt  by  gently  introducing 


cp  ecnviCAL 


ACUTE    LARYNGITIS  429 

the  finger  and  exploring  the  posterior  phar}'ngeal  wall.  Great  care  should 
be  exercised  in  making  this  examination  not  to  rupture  the  abscess  pre- 
maturely. 

Prognosis. — Wlien  the  disease  is  discovered  early,  and  properly  treated, 
there  is  little  danger  to  life;  nearly  all  such  cases  promptly  recover.  If 
the  abscess  burrows  and  finally  ruptures  spontaneously  the  child  may  be 
suffocated  by  the  pus. 

Treatment. — There  should  be  no  delay  in  opening  the  abscess  after 
it  has  been  discovered.  In  making  this  operation,  care  should  be  exercised 
to  prevent  the  contents  of  the  abscess  from  passing  into  the  larynx.  The 
child  should  be  placed  on  its  back  and  its  head  allowed  to  hang  over  the 
edge  of  the  table  (Rose  position)  and  a  mouth-gag  introduced.  With 
the  index  finger  of  one  hand  as  a  guide,  a  pointed  hemostatic  forceps,  with 
the  blades  closed,  should  be  forced  into  the  abscess  cavity  and  then  the 
blades  separated  until  the  pus  has  been  evacuated.  The  child's  head 
should  be  securely  held  until  the  danger  of  aspirating  the  pus  is  over. 
General  anesthesia  is  to  be  avoided  (Iglauer).  To  prevent  refilling  of  the 
abscess  it  is  sometimes  necessary  to  introduce  a  probe  or  finger  into  the 
opening  once  a  day  for  two  or  three  days  following  the  operation.  In 
rare  instances  the  deeper  lymphatics  are  involved  and  the  abscess  points 
not  only  into  the  pharynx,  but  also  into  the  neck.  In  such  cases  the  ab- 
scess cavity  should  be  opened  externally.  This  operation,  however,  is  more 
difficult  and  should  be  done  by  a  surgeon.  Following  the  opening  of  such 
an  abscess  externally,  it  should  be  drained  and  given  proper  surgical 
treatment,  until  it  gradually  heals  from  within  outward. 


CHAPTER   XLIX 

DISEASES     OF    LAEYNX 

ACUTE   LARYNGITIS 

This  is  an  acute  catarrhal  inflammation  of  the  larynx,  which,  in  infants 
and  young  children,  is  commonly  associated  with  spasm  of  the  glottis.  For 
this  reason  it  is  popularly  spoken  of  as  false  croup,  spasmodic  croup,  or 
catarrhal  croup. 

Etiology. — Laryngitis  may  occur  as  a  primary  infection,  but,  as  a  rule, 
it  is  secondary  to  catarrhal  processes  of  the  throat  or  nasopharynx. 
Rhinitis,  more  or  less  severe,  is  its  most  common  antecedent.  Laryngitis 
may  also  be  a  part  of  the  symptom  group  in  measles,  influenza  and  whoop- 
ing-cough. Cases  associated  with  measles  are  not  infrequently  very  violent 
in  character.  The  pathogenic  microorganisms  capable  of  producing  acute 
laryngitis  are  very  frequently  found  on  the  normal  mucous  membranes 
of  the  throat  and  nose,  and  long  exposure  to  damp,  cold,  or  raw  winds 
may  cause  a  congestion  of  these  mucous  surfaces,  and  thus  make  it  possible 


430  DISEASES  OF  LARYNX 

for  these  microorganisms  to  incite  a  laryngitis.  Laryngitis  is  much  more 
common  in  the  young  child;  when  it  does  occur  in  older  children  the 
spasmodic  element,  which  is  partly  responsible  for  the  laryngeal  stenosis, 
is  absent,  and  the  disease  runs  a  comparatively  mild  course  without  alarm- 
ing symptoms.  The  spasmodic  form  of  this  disease,  called  "false  croup," 
occurs  most  frequently  between  the  end  of  the  first  and  the  fifth  year  of 
life.  It  may  occur  even  during  the  first  year,  and  in  neurotic  children, 
who  have  been  subject  to  croup,  it  may  occur  after  the  sixth  year.  One 
attack  predisposes  to  another.  There  may  also  be  a  family  predisposition 
to  this  disease.  It  is  especially  common  in  malnourished,  neurotic  children. 
The  hereditary  factor  in  many  cases  may  be  a  nervous  one.  Rickets, 
chronic  glandular  tuberculosis,  chronic  anemia,  a^id  mouth  breathing  are 
important  predisposing  factors.  Acute  laryngitis  not  only  occurs  more 
commonly  in  highly  nervous,  malnourished  children,  but,  in  this  type  of 
child,  the  spasmodic  element  is  much  more  severe  and  the  attack  of  croup 
is  therefore  much  more  alarming. 

The  pathological  condition  causing  this  symptom  group  is  the  con- 
gested, swollen,  and  inflamed  subglottic  mucous  membrane  of  the  larynx, 
covered  with  more  or  less  mucus.  This  greatly  interferes  with  the  free 
passage  of  air  through  the  larynx  and  produces  an  inspiratory  dyspnea. 
When  to  this  is  added  spasm  of  the  glottis,  the  laryngeal  stenosis  may 
for  a  time  be  almost  or  quite  complete. 

Symptomatology. — Catarrhal  laryngitis,  as  it  occurs  in  the  older  child, 
unassociated  with  spasm  of  the  glottis,  may  be  a  primarj^  or  secondary 
process.  It  is  commonly  preceded  by  rhinitis,  pharyngitis,  or  tonsillitis, 
or  associated  with  influenza  or  measles.  The  fever,  which  is  almost  con- 
stantly present  in  these  cases,  is  in  no  way  characteristic,  and  adds  little 
to  the  diagnosis  of  the  disease.  It  is  usually  slight  and  variable,  ranging 
from  normal  to  101°  or  102°  F.;  in  severe  cases  it  may  reach 
104°  F.  High  fever  not  infrequently  depends  upon  the  associated  disease, 
such  as  influenza.  The  cough,  dyspnea,  and  hoarseness  are  more  or  less 
characteristic  symptoms.  The  cough  is  harsh  and  croupy  in  character;  the 
most  pronounced  croupiness  usually  occurs  at  the  onset,  or  at  least  early 
in  the  disease,  and  gradually  disappears,  leaving  a  laryngeal,  tracheal,  or 
bronchial  cough  which  lasts  for  a  week  or  ten  days.  The  cough  is  the 
most  persistent  symptom;  it  may  be  paroxysmal,  almost  incessant,  or  nag- 
ging in  character.  The  voice  is  hoarse,  and,  in  some  instances,  almost  lost, 
but  the  hoarseness,  like  the  cough,  is  an  early  symptom  which  gradually 
subsides.  Dyspnea  is  a  more  or  less  marked  symptom,  but  is  not  so  prom- 
inent in  older  children ;  the  difficulty  in  breathing  when  it  exists  is  as- 
sociated with  an  inspiratory  stridor.  All  of  the  above  symptoms  are  more 
aggravated  at  night.  Such  is  the  clinical  picture  presented  by  laryngitis 
in  the  older  child,  and  it  differs  little  from  that  seen  in  the  adult,  except 
that  perhaps  in  the  child  the  cough  is  more  croupy  and  associated  with 
more  dyspnea. 

The  clinical  picture,  however,  produced  by  false  croup  in  the  young 


ACUTE    LARYNGITIS  431 

child  is  very  difPoront  from  the  one  just  descrilied.  There  are  few 
clinical  syndromes  wJiich  cause  more  widespread  alarm  in  a  household  than 
an  attack  of  spasmodic  croup.  The  young  child  may  go  to  bed  without 
premonitory  symptoms,  but  usually  there  is  some  slight  warning  during  the 
day  or  late  afternoon  in  tlie  form  of  a  slightly  hoarse  cough,  which  may 
or  may  not  be  associated  with  coryza  or  pharyngitis.  The  child,  however, 
does  not  appear  to  be  very  ill  and  his  temperature  is  but  slightly  above 
normal.  He  falls  asleep  as  usual  and,  commonly  before  midnight,  awakens 
with  a  harsh,  croupy  cougli,  which  can  be  heard  even  in  adjoining  rooms. 
It  is  accompanied  by  great  difficulty  in  breathing,  an  inspiratory  stridor 
and  very  pronounced  hoarseness.  The  difficulty  in  breathing  increases, 
the  face  becomes  cyanosed,  and  the  child  is  apparently  threatened  with 
immediate  suffocation.  If  the  attack  be  a  severe  one,  the  mother  and 
other  attendants  are  thrown  into  a  state  of  anxiety  bordering  on  panic; 
this  excites  and  alarms  the  child  and  perhaps  aggravates  the  attack.  The 
dyspnea  in  these  cases  is  so  pronounced  that  all  the  accessory  muscles  of 
inspiration  are  brought  into  play;  there  are  wide  flaring  of  the  nostrils 
and  a  deep  sinking  in  at  the  suprasternal  notch  and  diaphragmatic  groove. 
Attacks  of  such  severity  commonly  last  from  a  few  minutes  to  one-half 
hour.  Great  difficulty  in  breathing,  however,  may  continue  for  hours.  As 
the  attack  subsides  the  child's  breathing  becomes  less  harsh  and  less  la- 
bored, and  it  falls  back  more  or  less  exhausted  upon  the  bed  and  sleeps 
until  morning.  Following  the  attack,  its  clothing  is  wet  with  perspira- 
tion. In  rare  instances  more  than  one  attack  may  occur  during  a  night. 
The  following  morning  the  child  is  found  wdth  perhaps  little  or  no  fever; 
it  is  bright,  feels  well  and  desires  to  get  out  of  bed  as  usual.  The  bark- 
ing cough,  the  dyspnea,  and  the  hoarseness  have  all  largely  disappeared. 
There  may  be  some  inspiratory  stridor;  whistling  rales  may  be  heard  in 
the  large  bronchi;  hoarseness  may  still  be  present  to  a  slight  degree;  the 
cough,  which  has  lost  its  hoarse,  metallic  character,  still  persists,  and 
throughout  the  day  it  is  a  prominent  and  irritating  symptom.  If  the  child 
is  allowed  to  go  about,  and  especially  if  it  is  not  properly  treated,  the 
cough,  dyspnea,  and  hoarseness  gradually  increase  as  bed-time  approaches, 
and  the  child  falls  asleep  and  has  another  attack,  perhaps  near  the  same 
hour  as  the  first  night;  it  is,  however,  usually  less  severe.  The  second 
day  the  child  again  appears  convalescent,  but  on  the  third  night  another 
and  milder  attack  may  occur.  These  croupy  attacks  do  not  usually  recur 
for  more  than  three  nights  in  succession  and  their  severity  will  depend 
upon  the  treatment  instituted,  as  well  as  upon  the  physical  condition 
of  the  patient;  nervous,  malnourished  children  are  more  subject  to  severe 
and  recurring  attacks.  The  fever  may  continue  for  three  or  four  days 
and  the  cough  usually  lasts  for  a  week  or  ten  days.  After  the  second  or 
third  day  it  gradually  becomes  tracheal  and  bronchial  in  character,  the 
croupiness,  hoarseness,  and  dyspnea  being  no  longer  present. 

Diagnosis. — Catarrhal    croup   must    be   differentiated   from   laryngeal 
diphtheria.     This,  as  a  rule,  is  not  difficult;  there  is  no  preliminary  his- 
29 


432  DISEASES  OF  LABYNX 

tory  of  sore  throat,  no  membrane  is  present  on  the  tonsils  or  pharynx, 
and  the  onset  of  the  disease  is  sudden.  The  greatest  dyspnea,  the  hoarsest 
cough,  and  the  most  marked  aphonia  occur  during  the  first  night,  and  all 
of  these  symptoms  almost  disappear  the  next  morning,  possibly  to  recur 
the  next  night  or  two,  diminishing  in  violence.  This  is  in  marked  contrast 
with  the  gradual  onset  of  diphtheritic  laryngitis,  in  which  the  dyspnea, 
hoarseness,  and  croupiness  come  on  slowly  and  gradually,  from  two  to 
three  days  being  required  to  produce  a  dangerous  laryngeal  stenosis;  the 
inspiratory  stridor  continues  during  the  day,  although  the  whole  symptom 
group  may  be  more  aggravated  at  night.  In  clearly  defined  cases  the 
differential  diagnosis  is  simple,  but  now  and  again  we  may  have  a  primary 
laryngeal  diphtheria  which  can  scarcely  be  differentiated  from  ordinary 
acute  laryngitis,  and  occasionally  we  may  have  very  severe  attacks  of 
acute  laryngitis,  in  which  the  symptoms,  more  or  less  modified,  persist 
during  the  following  day  and  recur  with  marked  severity  the  following 
night.  In  such  cases  it  m.ay  be  absolutely  impossible  to  make  a  differential 
diagnosis,  therefore  the  child  should  be  given  a  large  dose  of  antitoxin 
(see  Diphtheria),  and  careful  bacteriological  cultures  from  the  lar5'nx 
made  to  determine  the  presence  or  absence  of  the  Klebs-Loffler  bacillus. 
The  diphtheria  antitoxin  in  these  cases  should  be  given  as  a  diagnostic 
measure,  without  awaiting  the  results  of  a  bacteriological  examination. 
A  laryngoscopic  examination  may  reveal  the  presence  of  a  membrane  in 
doubtful  cases. 

Prognosis. — The  prognosis  is  good.  Fatal  cases,  however,  have  been 
recorded.  Bronchitis,  which  is  the  common  and  usual  complication,  pro- 
longs the  cough  and  other  symptoms.  Pneumonia,  which  is  a  com- 
paratively rare  complication,  may  terminate  fatally. 

Treatment. — If  the  child  is  seen  for  the  first  time  during  the  severe 
spasmodic  attack  an  emetic  is  indicated;  teaspoonful  doses  of  syrup  of 
ipecac  may  be  given  every  half  hour  until  vomiting  is  produced ;  as  a  rule, 
only  one  dose  is  necessary.  The  emetic  clears  out  the  pharyngeal  and 
perhaps  some  of  the  laryngeal  mucus,  but,  more  important  than  this,  it 
relieves  the  laryngeal  spasm,  and  thus  controls  the  severe  dyspnea  in  a 
short  time.  Following  the  emetic,  the  child's  stomach  should  be  allowed 
to  rest,  undisturbed  by  medicine  or  food;  some  hours  later  liquid  food 
and  the  following  prescription  may  be  given: 

Potassium  bromid      grs.  60 

Antipyrin     gre.  15 

Glycerin    j  i 

Elixir  of  lactated  pepsin ad    |  ii 

Sig.  A  teaspoonful  every  three  hours  to  a  child  two  or  three  years  of  age. 

The  bromid  of  potash  and  antipyrin  in  the  above  prescription  are  to 
be  increased  or  diminished  to  suit  the  age  of  the  child.  In  children  over 
three  years  of  age  one  drachm  of  syrup  of  ipecac  may  take  the  place  of 
the  glycerin  in  this  prescription.     This  remedy  is  to  be  given  every  three 


ACUTE    LARYNGITIS  433 

hours  the  first  day,  every  four  or  five  hours  the  second  day,  and  thereafter 
one  dose  at  bed-time  for  four  or  five  days.  This  will  almost  always  pre- 
vent second  and  third  attacks,  and  will  also,  in  the  great  majority  of 
instances,  prevent  the  first  attack,  if  the  preliminary  symptoms  give  suf- 
ficient warning  to  permit  the  giving  of  several  doses  of  this  remedy  during 
the  preliminary  hoarseness,  which  sometimes  precedes  these  attacks. 
Mothers  having  croupy  children  should  be  provided  with  this  mixture 
and  advised  to  give  it  with  the  onset  of  any  catarrhal  condition  of  the 
throat  or  nose,  especially  if  it  be  associated  with  the  slightest  hoarseness. 
In  severe  cases,  where  the  emetic  does  not  act  promptly,  or  where  it  fails 
to  give  relief,  a  few  inhalations  of  chloroform  may  be  given  to  relieve 
the  spasm  of  the  glottis.  This  is  indicated  only  where  cyanosis  is  marked 
and  difficulty  of  breathing,  almost  to  the  point  of  suffocation,  is  present. 
In  .some  instances  the  laryngeal  stenosis  may  be  so  great,  and  the  diagnosis 
between  acute  laryngitis  and  laryngeal  diphtheria  so  ill  defined,  that  intuba- 
tion and  a  good-sized  dose  of  diphtheria  antitoxin  may  be  advisable.  In 
ordinary  laryngitis  these  remedies  can  do  no  harm  and  in  diphtheritic 
laryngeal  stenosis  they  are  life-saving  measures.  If  the  bacteriological 
examination  and  the  subsequent  clinical  history  show  the  case  to  be  one  of 
true  diphtheria  of  the  larynx,  much  valuable  time  will  have  been  saved, 
and  the  patient's  chances  for  life  will  be  much  better  by  having  given  the 
antitoxin. 

The  child  should  be  kept  in  bed  on  the  day  following  the  attack  and 
perhaps  as  long  as  the  fever  and  croupy  cough  are  present.  It  is  also  al- 
most universally  recommended  that  children  suffering  from  laryngitis 
should  breathe  warm,  moist  air.  Croup  tents  of  various  kinds  are  used 
for  this  purpose.  The  bed  is  so  tented  that  steam  from  a  croup-kettle,  or 
some  other  steam  generator,  can  be  directed  into  it.  By  this  device  the 
child  is  made  to  breathe  warm  air  heavily  laden  with  moisture.  Tincture 
of  benzoin,  turpentine  and  guaiacol  may  be  added  to  the  water  from  which 
the  steam  is  made.  These  drugs,  when  inhaled,  are  believed  to  have  a 
soothing  and  antiseptic  effect.  While  the  croup  tent  may  be  of  value,  my 
own  experience  is  that  it  does  very  little  good.  I  have  not  used  it  in  the 
past  five  years  in  the  treatment  of  any  kind  of  croup.  These  children  do 
better  in  rooms  having  a  temperature  of  about  70°  F.,  well  ventilated  with 
fresh,  comparatively  warm  air,  carrying  a  moderate  amount  of  moisture. 
Warm  applications  to  the  neck  in  the  form  of  hot  fomentations  or  hot 
poultices  are  of  value  in  relieving  the  spasm  of  the  initial  attack  as  well 
as  in  preventing  second  and  third  attacks.  Warm  baths  have  a  soothing 
and  relaxing  effect.  During  convalescence,  syrup  of  hydriodic  acid,  syrup 
of  the  iodid  of  iron,  cod-liver  oil,  and  other  tonics  are  of  value. 

The  treatment  of  so-called  croupy  children  during  the  interval  between 
attacks  is  most  important.  They  should  avoid,  if  possible,  all  contagion 
and  exposure  to  damp  cold;  should  be  warmly  clad  during  the  cold,  damp 
months  of  winter;  should  live  in  the  fresh  air  during  the  day  and  sleep 
in  it  during  the  night ;  they  should  be  built  up  by  careful  feeding,  regular 


434  DISEASES  OF  LARYNX 

diet,  and  suitable  tonics,  such  as  cod-liver  oil,  malt,  and  iron,  and,  if 
they  have  a  chronic  tonsillar  hypertrophy,  or  adenoid  growths,  these  should 
be  removed. 

EDEMA    OF    THE   LARYNX 

Edema  of  the  larynx,  incorrectly  called  edema  of  the  glottis,  is  an 
edematous  swelling  of  the  submucous  cellular  tissues  of  the  larynx  and  the 
aryepiglottic  folds.  This  edema  may  be  a  simple  serous  infiltration,  due 
to  causes  remote  from  the  larynx,  not  associated  with  acute  inflammation; 
in  such  cases  the  edematous  mucous  membrane  may  be  pale  or  slightly 
congested.  But  in  the  most  common  group  of  cases  it  is  secondary  to  an 
acute  submucous  inflammation  of  the  larynx;  in  this  form  the  exudate  is 
seropurulent  in  character,  and  the  mucous  membrane  of  the  larynx  is 
red,  swollen,  ulcerated,  and  sometimes  lacerated. 

Etiology. — The  simple  serous  infiltration  from  constitutional  causes  is 
comparatively  rare  in  the  child;  it  may  be  produced  by  acute  and  chronic 
nephritis,  cardiac  insufficiency,  and  by  lymph  nodes,  and  other  tumors, 
the  pressure  of  which  prevents  normal  circulation  in  the  larynx.  The 
inflammatory  form  is  due  to  infection  and  subsequent  inflammation,  or  to 
foreign  bodies  in  the  larynx,  or  injuries  of  the  mucous  membrane,  pro- 
duced by  the  swallowing  of  corrosive  chemicals  or  the  inhalation  of 
steam  or  irritating  vapors.  It  also  occurs  as  a  rare  complication  of  syphilis, 
smallpox,  chickenpox,  scarlet  fever,  diphtheria,  measles,  and  other  infec- 
tions, which  may  excite  inflammation  of  the  laryngeal  mucous  membrane. 

Symptomatology. — The  most  important  symptom  group  is  that  pro- 
duced by  the  laryngeal  stenosis.  An  inspiratory  dyspnea,  which,  in  se- 
vere cases,  threatens  or  even  takes  the  life  of  the  child  by  suffocation,  is 
the  important  symptom.  The  child  struggles  for  breath,  is  cyanotic,  all 
the  accessory  muscles  of  inspiration  are  brought  into  play,  orthopnea, 
laryngeal  stridor,  and  aphonia  are  present.  In  the  inflammatory  cases 
the  child  complains  of  pain  in  the  region  of  the  larynx.  The  suddenness 
of  the  onset  of  the  above  symptom  group  largely  depends  on  the  exciting 
cause;  following  severe  traumas  it  is  more  rapid  in  its  development.  As  a 
rule,  the  diagnosis  may  be  confirmed  by  introducing  the  finger  so  as  to 
come  in  contact  with  the  edematous  aryepiglottic  folds,  or  by  using  the 
laryngeal  mirror  or  the  direct  laryngoscope  to  bring  the  edematous  tissues 
into  view. 

Prognosis. — The  prognosis  will  depend  largely  upon  the  exciting  cause, 
and  ofttimes  upon  the  promptness  with  which  the  symptoms  are  relieved 
by  surgical  or  other  measures.  Untreated  cases  very  frequently  terminate 
by  suffocation.  The  milder  types  of  the  disease,  due  to  constitutional 
causes,  usually  yield  to  the  proper  medical  treatment  of  the  exciting  cause. 

Treatment. — If  marked  cyanosis  is  present  and  the  child  is  threatened 
with  suffocation  immediate  intubation  should  be  resorted  to.  In  an  in- 
stance that  came  under  my  observation  about  fifteen  years  ago  a  suffo- 


FORETGX    BODIES  435 

catin*j  edema  of  the  larynx  was  produced  In"  a  small  foreign  body.  When 
the  tube  was  introduced  the  child  was  blue  and  seemed  almost  moribund, 
but,  immediately  following  the  introduction  of  the  tube,  the  child  com- 
menced to  breathe,  and  within  one-half  hour  all  evidences  of  cyanosis 
had  disa}Dpeared.  In  this  instance  the  foreign  body,  which  was  the  hook 
of  an  ordinary  hook  and  eye,  was  pushed  into  the  trachea,  where  it  re- 
mained for  six  weeks,  producing  a  most  irritating  cough  and  more  or 
less  bronchitis.  It  was  finally  coughed  up  and  the  child  had  a  rapid 
recovery.  In  some  instances  it  may  be  necessary  to  perform  tracheotomy 
and  allow  the  tube  to  remain  in  the  trachea  until  the  edema  of  the  larynx 
has  disappeared.  Scarification  of  the  edematous  tissue  in  some  instances 
gives  relief.  All  of  these  operative  measures,  however,  should  be  carried 
out,  if  possible,  by  a  specialist.  The  medical  treatment  of  the  localized 
inflammation  in  the  larynx  is  the  same  as  that  previously  recommended 
for  ordinary  laryngitis.  Where  heart  disease  and  acute  nephritis  are 
the  exciting  causes  these  conditions  must  receive  treatment.  Hot  baths, 
diaphoretics,  and  saline  laxatives  are  indicated  in  nephritis.  Digitalis, 
absolute  rest,  and  a  dry  diet,  containing  not  more  than  a  pint  and  a  half 
of  liquid  in  twenty-four  hours,  are  indicated  in  heart  disease. 

NEOPLASMS   IN   THE   LARYNX 

This  is  a  comparatively  rare  condition  and  is  essentially  a  surgical  one. 
Of  laryngeal  tumors,  papillomata  are  the  most  common.  Fibromata  and 
malignant  growths  also  occur. 

The  diagnosis  in  these  cases  is  made  by  the  slow  onset  of  an  inspiratory 
dyspnea,  commonly  associated  with  increasing  hoarseness,  and  sometimes 
with  an  increasing  cough.  A  laryngoscopic  examination  reveals  the  pres- 
ence of  the  tumor.  These  cases  should  always  be  referred  to  the  spe- 
cialist for  surgical  treatment.  The  relief  following  the  removal  of  papil- 
loma of  the  larynx  is  pronounced  and  immediate,  but  frequently  after 
some  months  the  return  of  the  growth  is  announced  by  the  slow  return 
of  the  symptoms  of  laryngeal  stenosis,  and  second  and  third  operations 
may  be  necessary.  The  long-continued  use  of  Fowler's  solution  is  said  to 
prevent  recurrence  after  operation. 

FOREIGN  BODIES  IN  THE  LARYNX,  TRACHEA  AND  IN 

THE  BRONCHI 

Foreign  bodies  in  their  passage  to  the  bronchi  not  infrequently  lodge 
for  a  time  in  the  larynx,  producing  violent  irritation  of  this  organ, 
sometimes  resulting  in  edema  of  the  larynx,  but  in  most  instances,  after 
a  violent  fit  of  coughing  and  strangling  with  more  or  less  dyspnea,  they 
are  either  dislodged  outwardly  from  the  larynx,  or  pass  into  the  trachea, 
where  they  cause  more  or  less  irritation. 

All  kinds  of  small  foreign  bodies  may  find  their  way  into  the  trachea 


436 


DISEASES    OF   LARYNX 


and  small  bronchial  tubes.  Particles  of  food,  buttons,  coins,  grains  of  corn, 
pebbles,  and  all  the  small  objects  with  which  children  commonly  play,  may 
be  aspirated  into  the  trachea  and  bronchi.  As  previously  noted,  in  their 
passage  through  the  larynx  they  may  excite  symptoms  of  acute  laryngeal 
stenosis,  but  after  passing  into  the  trachea  and  bronchi  there  is  great 
variation  in  the  symptoms  they  produce.    As  a  rule,  cough  of  a  paroxysmal 


Fig.  69. — Marked  Dilatation  of  the  Right  Lung,  Produced  by  Foreign  Body 
IN  THE  Right  Bronchus.     (Iglauer.) 

and  aggravated  type  is  a  prominent  symptom,  and  a  whistling  bronchitis 
of  the  larger  tubes  is  nearly  always  present.  I  recently  saw  a  case  produced 
by  the  kernel  of  a  peanut  in  the  right  bronchial  tube.  This  child  was  two 
years  of  age  and  had  been  treated  for  some  months  for  asthma.  Its  breath- 
ing was  labored,  and  large  sibilant  rales  could  be  heard  over  both  lungs. 
The  respiratory  movements  on  the  left  side  were  more  marked  than  on 
the  right,  and  the  vesicular  murmur  was  markedly  diminished  on  the  right. 
These  physical  signs,  in  the  absence  of  dullness,  indicated  plainly  that 


CONGENITAL   LARYNGEAL    STRIDOR  437 

the  air  was  passing  into  the  left  lung  much  more  readily  than  into  the 
right,  and  the  diagnosis  of  a  foreign  body  in  the  right  bronchus  was 
made.  The  X-ray  picture  here  presented  failed  to  reveal  the  presence 
of  the  foreign  body,  and  also  for  a  time  added  confusion  to  the  clinical 
picture  by  showing  that  the  right  lung  was  distended  and  contained  more 
air  than  the  left.  The  foreign  body,  which  was  afterwards  located  and 
removed  from  the  right  bronchus,  acted  as  a  valve,  which  impeded  ex- 
piration more  than  inspiration.  In  most  of  these  cases,  however,  the  re- 
verse of  this  is  true,  and  the  X-ray  picture  may  show  the  lung  fed  by  the 
obstructed  bronchus  to  contain  less  air  than  the  other.  In  many  instances 
also  the  foreign  body  is  of  such  a  character  that  it  can  be  located  by  an 
X-ray  picture.  Increased  respiratory  movements  on  one  side  and  di- 
minished vesicular  murmur  on  the  other,  occurring  in  a  young  child 
which  has  a  troublesome  cough  and  whistling  bronchitis  without  fever  or 
the  physical  signs  of  pneumonia,  should  be  sufficient  to  suggest  the  diag- 
nosis of  an  obstructed  bronchus.  In  addition  to  this,  there  is  usually  a 
history  of  an  acute  attack  of  strangling  with  acute  laryngeal  irritation,  as 
the  result  of  "swallowing  some  foreign  body  the  wrong  way."  In  some 
instances  these  foreign  bodies  may  remain  for  months  or  years  without 
seriously  interfering  with  the  health  of  the  child,  and  then  again,  after  a 
long  period  of  quiescence,  they  may  produce  hemoptysis,  or  a  circumscribed 
bronchopneumonia.  The  ultimate  diagnosis  is  made  by  the  specialist, 
who  locates  the  foreign  body  by  the  bronchoscope.  In  the  use  of  this  in- 
strument it  is  sometimes  necessary  to  make  a  preliminary  tracheotomy. 
This  is  especially  true  of  the  infant,  in  whom  it  is  frequently  impossible 
or  impracticable  to  use  the  bronchoscope  through  the  larynx. 

Prognosis. — Under  proper  treatment  the  prognosis  is  usually  good.  In 
the  hands  of  a  specialist,  skilled  in  the  use  of  the  proper  instruments, 
foreign  bodies,  even  though  they  be  well  down  in  the  bronchial  tubes,  can 
be  rather  readily  removed.  The  prognosis  in  untreated  cases  is  usually 
very  bad.  The  foreign  bodies  in  time  may  produce  a  fatal  inflammation 
of  the  pulmonary  tissues. 

CONGENITAL   LARYNGEAL   STRIDOR 

This  is  a  rare  congenital  condition,  the  etiology  of  which  is  unknown. 
The  infantile  character  of  the  larynx  persists,  and  the  epiglottis  is  turned 
back,  so  that  the  lateral  edges  come  in  contact,  leaving  a  very  narrow 
opening  between  the  aryepiglottic  folds,  producing  a  valve-like  condition 
which  obstructs  the  intake  of  air. 

Symptomatology. — The  stridor  is  purely  inspiratory  and,  according  to 
Thomson,  consists  of  a  loud  crackling  or  croaking  sound  on  inspiration, 
accompanied  by  the  physical  signs  of  an  inspiratory  dyspnea.  Expiration, 
on  the  other  hand,  is  easy  and  noiseless,  and  cyanosis,  as  a  rule,  is  not 
marked.  The  stridor  varies  greatly  in  its  intensity,  and  may  at  times 
entirely  disappear  and  then  again  recur  under  nervous   excitement,  or 


438  BRONCHITIS 

catarrhal  conditions  of  the  larynx.  The  paroxysms  of  dyspnea,  as  a  rule, 
increase  in  severity  during  the  first  six  months  of  life  and  then  gradually 
subside,  to  disappear  before  the  end  of  the  second  year. 

This  condition  may  be  differentiated  from  laryngismus  stridulus,  thymic 
asthma,  papilloma,  and  other  obstructive  lesions  of  the  larynx  by  the 
fact  that  it  begins  at  or  immediately  after  birth  and  by  the  characteristic 
syndromes  of  the  above-named  conditions. 

Treatment. — The  child  should  be  protected  from  nervous  excitement 
and  should  be  carefully  guarded  from  all  contagions  which  may  produce 
catarrhal  conditions  of  the  nasopharynx.  Fresh  air,  careful  feeding,  and 
all  measures  which  will  improve  the  physical  condition  of  the  infant  will 
modify  the  severity  of  the  paroxysms  and  shorten  the  course  of  the  disease. 
The  prognosis  in  uncomplicated  cases  is  good. 


CHAPTER  L 
BEONCHITIS 

ACUTE    CATARRHAL    BRONCHITIS 

Bronchitis  is  a  catarrhal  inflammation  of  the  bronchial  mucous  mem- 
brane which,  especially  in  infancy,  has  a  tendency  to  spread  downward 
and  involve  the  small  bronchi. 

Etiology. — Glandular  tuberculosis,  rickets,  syphilis,  anemia  and  clironio 
diseases  of  the  adenoids,  tonsils,  pharynx,  and  nasal  mucous  membrane 
are  the  most  important  predisposing  causes. 

Infection  is  the  essential  factor  in  the  etiology  of  acute  bronchitis. 
The  most  common  exciting  microorganisms  are  the  staphylococcus  aureus, 
the  pneumococcus,  the  streptococcus,  the  influenza  bacillus,  and  the  bacil- 
lus catarrhalis,  but  it  may  be  produced  by  typhoid,  diphtheria,  and  tubercle 
bacilli,  and  it  is  commonly  associated  with  epidemic  grippe,  measles,  per- 
tussis, and  scarlet  fever.  The  influenza  bacillus  is  commonly  responsible 
for  the  chronic  form  of  bronchitis. 

The  great  majority  of  these  cases  occur  during  the  winter  or  spring 
months.  This  is  partly  because  the  contagions  wliich  produce  bronchitis 
are  rife  at  this  time,  but  also  because  this  is  the  season  when  children  are 
huddled  together  in  close,  ill-ventilated  rooms,  not  only  at  school  but  in 
their  homes.  They  are  thereby  forced  to  breathe  an  impure,  germ-laden 
air,  which  is  the  direct  cause  of  bronchitis.  If  the  laity  could  get  away 
from  the  bugbear  that  "catching  cold"  is  the  all-important  cause  of  this 
disease  and  learn  that  the  way  to  avoid  bronchitis  is  to  live  and  sleep  in  the 
open  air,  the  morbidity  and  mortality  from  this  disease  would  be  enor- 
mously decreased.  I  do  not  wish  to  convey  the  impression  that  prolonged 
exposure  to  damp  cold  can  do  no  harm  ;  on  the  contrary,  it  is  an  important 
exciting  cause  of  bronchitis.     This  factor,  however,  can  only  excite  bron- 


ACUTE    CATAREHAL    BRONCHITIS  439 

chitis  in  children  who  carry  upon  their  respiratory  mucous  membranes 
one  or  other  of  the  microorganisms  which  may  cause  this  disease.  I 
do  not  believe  it  is  wise  to  expose  the  legs  or  other  portions  of  the  body 
to  damp  cold,  with  the  idea  that  it  exercises  a  hardening  influence  upon 
the  child  and  prevents  disease.  It  is  not  desirable  that  the  skin  of  the 
child  should  be  hardened,  but  only  that  it  should  breathe  fresh  air.  During 
the  winter  months,  in  order  that  this  may  be  accomplished  with  safety,  it 
is  not  only  wise  but  advisable  that  the  child  should  be  properly  clothed 
so  that  all  portions  of  his  body  may  be  comfortably  warm. 

Age  is  an  important  predisposing  factor.  Bronchitis  is  most  com- 
mon between  the  sixth  month  and  the  end  of  the  third  year  of  life. 
After  this  time  it  rapidly  decreases  in  frequency. 

Pathology.  ^ — The  mucous  membrane  of  the  trachea  and  bronchi  is  con- 
gested and  swollen,  its  blood  vessels  dilated,  and  its  secreting  structures, 
especially  the  mucous  cells,  increased  in  size  and  activity.  The  mucosa 
and  submucosa  are  infiltrated  with  small,  round  cells,  and  with  the  bac- 
teria producing  the  disease.  The  bronchi  contain  more  or  less  mucus  or 
a  mucopurulent  exudate.     The  peribronchial  tissues  are  not  involved. 

Symptomatology.  • — Fever  and  cough  announce  the  onset  of  simple  bron- 
chitis. There  is  nothing  characteristic  in  the  fever.  It  rises  gradually 
to  102°  or  104°  F.,  is  irregular  in  character,  runs  a  short  course,  and 
usually  reaches  normal  in  from  four  to  seven  days.  It  runs  an  afebrile 
course  in  very  young  infants,  and  even  in  older  ones,  suffering  from  gastro- 
intestinal disease,  rickets,  or  other  malnutritions.  In  those  cases  asso- 
ciated with  influenza  and  other  acute  infections  the  high  fever  seen  in 
the  beginning  is  due  to  the  general  toxemia.  As  this  subsides,  the  lower 
and  irregular  temperature  of  bronchitis  may  continue  for  a  number  of 
days  before  it  reaches  normal.  If  the  fever  remains  high  and  prolonged, 
it  is  an  evidence  of  a  beginning  bronchopneumonia,  otitis  media,  or  some 
other  complication.  The  cough  is  the  most  prominent  and  the  most 
troublesome  symptom.  It  is  always  present,  except  in  very  young  and 
feeble  infants,  and  directs  attention  to  the  lungs  as  the  site  of  the  disease. 
In  the  beginning  it  is  usually  dry,  irritating  and  unproductive;  at  this 
time  the  child  is  not  seen  to  swallow  following  the  cough.  Later  it  is 
loose,  less  paroxysmal,  and  less  troublesome,  and  usually  gives  more  or 
less  relief  as  it  brings  up  into  the  pharynx  some  of  the  mucus  which  the 
child  is  seen  to  swallow  following  the  cough  paroxysm.  In  some  instances 
the  cough  is  associated  with  pain  and  more  rarely  with  vomiting.  Children 
under  six  or  seven  years  of  age  do  not  usually  expectorate;  it  is  therefore 
difficult  to  obtain  specimens  of  sputum  for  examination.  If  this  is  thought 
necessary,  however,  the  sputum  may  be  obtained  by  wiping  out  the  pharynx 
with  a  gauze-wrapped  finger  or  a  cotton-wrapped  probe.  In  this  way  it 
may  be  possible  to  decide  whether  the  disease  is  produced  by  pneumococci, 
influenza  bacilli,  streptococci,  or  other  microorganisms.  Such  information 
is  of  little  or  no  value-  from  a  therapeutic  standpoint,  and  this  procedure 
therefore  is  hardly  justifiable  as  a  routine  method  of  differential  diagnosis. 


440  BRONCHITIS 

The  respiratory  movements  are  more  rapid  than  normal,  and  perhaps 
slightly  labored.  In  simple  bronchitis,  in  children  over  six  months  of  age, 
there  is  practically  no  evidence  of  dyspnea ;  when,  in  such  a  case,  therefore, 
the  wings  of  the  nose  begin  to  flare,  and  the  peripneumonic  groove  begins 
to  recede  with  each  inspiration,  it  is  time  for  the  physician  to  employ 
his  most  potent  remedies  to  prevent  the  onset  of  bronchopneumonia.  It 
should  be  remembered  that  there  is  also  a  form  of  afebrile  asthmatic  bron- 
chitis, presenting  all  the  evidences  of  increased  labor  on  the  part  of  the 
accessory  muscles  of  inspiration,  such  as  dilatation  of  the  alae  nasi,  sinking 
in  of  the  suprasternal  notch,  and  inspiratory  recession  of  the  walls  of 
the  chest  in  which,  notwithstanding  these  symptoms,  there  is  little  or  no 
danger  of  bronchopneumonia.  This  form  may  commonly  be  differentiated 
from  ordinary  bronchitis  by  the  inspiratory  stridor,  the  sibilant  rales,  and 
by  the  fact  that  the  child  has  little  or  no  fever.  In  very  young  and  deli- 
cate infants  there  is  even  in  simple  bronchitis  a  slight  amount  of  dyspnea 
with  flaring  of  the  nostrils  and  a  slight  recession  of  the  peripneumonic 
groove. 

Physical  Signs. — The  physical  signs  are  well  marked  and  by  them 
the  diagnosis  of  bronchitis  is  made.  In  almost  every  case  bronchial  fremi- 
tus may  be  felt.  The  vibrations  of  the  chest  wall  are  very  significant 
to  the  experienced  touch.  The  early  sibilant  and  whistling  rales,  and  the 
subsequent  mucous  rales,  which  may  be  heard  in  both  the  large  and 
medium-size  bronchi,  give  unmistakable  evidence  of  this  disease.  Fine 
crepitant  rales,  which  may  occur  at  any  time  during  the  progress  of  a 
bronchitis,  mean  the  onset  of  pneumonia.  Inspection  may  reveal  rapid 
breathing  and  a  slight  inspiratory  retraction  of  the  chest  wall.  This  is 
especially  true  in  young  and  delicate  children,  but  when  these  signs  are 
exaggerated  they  may  be  an  indication  of  a  beginning  bronchopneumonia. 
Percussion  is  of  comparatively  little  value  except  for  determining  when 
the  disease  is  passing  from  the  stage  of  bronchitis  to  that  of  pneumonia. 

The  course  of  simple  bronchitis  is  usually  from  four  to  eight  days ;  the 
disease,  however,  may  be  prolonged  with  intermissions  for  a  period  of 
from  four  to  five  weeks;  this  is  common  in  those  cases  associated  with 
subacute  or  chronic  disease  of  the  adenoids  and  tonsils.  Eeinfection  may 
cause  relapses  in  hospitals  and  even  in  private  homes  which  are  not 
properly  ventilated  and  disinfected  during  and  following  an  epidemic  of 
bronchitis. 

Complications. — Otitis  media,  mastoiditis,  bronchopneumonia,  intes- 
tinal toxemia,  and  gastroenteritis  are  common  and  dangerous  complica- 
tions. 

Prognosis. — The  prognosis  is,  on  the  whole,  good,  but  during  the  early 
weeks  of  life  it  should  be  guarded,  since  at  this  time  the  disease  may  run 
an  insidious  course  with  little  or  no  fever,  few  constitutional  symptoms, 
and  but  slight  cough,  and  yet,  during  all  of  this  time,  well-marked  physical 
signs  of  bronchitis  may  be  present,  and  a  fatal  l)ronchopneumonia  may 
develop  before  the  physician  is  aware  that  the  infant  is  seriously  ill. 


ACUTE    CATARRHAL    BROXCHITIS  441 

Prophylaxis. — Every  rhinitis,  pharyngitis,  or  slight  catarrh  of  the 
tracheal  or  bronchial  mucous  membranes  should  have  prompt  and  careful 
treatment;  this  especially  applies  to  the  new-born  and  to  syphilitic,  rachi- 
tic, and  other  malnourished  infants.  Breathing  pure  air,  living  out  of 
doors  during  the  day,  sleeping  with  open  windows  at  night,  and  wearing, 
during  the  cold  winter  months,  clothing  that  will  keep  the  skin  and  body 
warm  and  dry  are  important  prophylactic  measures.  All  contagion  should 
be  avoided.  Well  infants  should  be  kept  away  from  persons  suffering  from 
ordinary  colds,  tonsillitis,  grippe,  and  other  acute  infections.  In  children 
in  whom  the  disease  recurs  from  time  to  time,  or  who  have  a  tendency 
to  subacute  nasopharyngeal  catarrh,  the  throat  and  nose  should  be  in- 
spected and  all  diseased  tissues  removed. 

Treatment. — The  infant  or  child  with  acute  bronchitis  should,  if  pos- 
sible, be  confined  to  bed  in  a  large,  bright,  isolated  room,  the  windows  of 
which  are  opened  wide  enough  to  let  in  plenty  of  fresh  air.  Care  should 
be  taken  that  the  atmosphere  of  the  room  be  not  dried  out  with  artificial 
lieat ;  a  moist,  pure  air  is  soothing  to  the  irritated  bronchial  mucous  mem- 
branes. As  a  rule,  all  that  is  necessary  is  to  admit  the  outside  air;  this 
generally  secures  sufficient  moisture.  Where  this  cannot  be  satisfactorily 
accomplished,  the  air  of  the  room  may  be  moistened  by  heating  water  in 
an  open  vessel.  The  infant  or  child  should  be  clothed  so  that  its  body 
will  be  kept  warm  whatever  may  be  the  temperature  of  the  room.  In 
winter  the  bedroom  should  be  kept  between  60°  and  70°  F. 

The  medical  treatment  is  largely  symptomatic.  In  the  beginning,  if 
the  child  be  suffering  from  some  acute  intoxication,  such  as  influenza, 
which  produces  high  fever  and  marked  discomfort,  phenacetin  may  be 
given  for  one  or  two  days  but  should  not  be  continued  longer.  A  safe 
prescription  in  these  cases  is  guaiacol  carbonate,  1  grain;  salol,  1  grain, 
and  sugar,  1  grain.  This  dose  may  be  given  every  three  or  four  hours 
to  an  infant  under  one  year  of  age,  and  may  be  increased  to  suit  the 
age  of  the  child.  The  cough  may  be  allayed  by  the  use  of  bromid  of 
potash,  45  grains;  tincture  of  belladonna,  15  minims;  glycerin,  2  drachms, 
and  elixir  of  lactated  pepsin,  enough  to  make  2  ounces.  A  teaspoonful  of 
this  mixture  may  be  given  every  three  hours  to  an  infant  one  year  of 
age.  For  older  children,  syrup  of  ipecac,  1  drachm  to  the  ounce,  may 
be  added  to  this  prescription,  and  the  doses  of  the  other  ingredients 
increased  to  suit  the  age  of  the  child.  The  opium  preparations  are  almost 
never  indicated  in  children  under  two  years  of  age,  but  for  sturdy  children, 
over  this  age,  1  to  2  drachms  of  camphorated  tincture  of  opium  may  be 
added  to  the  above  prescription.  In  the  chapter  on  Bronchopneumonia 
I  have  spoken  most  decidedly  concerning  the  danger  of  giving  opium, 
cough  syrups,  ammonium  carbonate,  ammonium  muriate,  tartar  emetic, 
squills,  and  ipecac,  and  what  is  said  there  applies  with  almost  equal  force 
to  their  use  in  ordinary  bronchitis.  These  remedies  are  rarely  indicated, 
and  I  feel  quite  sure  that  more  harm  than  good  is  done  by  their  in- 
discriminate use  in  children  under  two  years  of  age. 


442  LOBAT?   PNEUMOXTA 

In  beginning  the  treatment,  the  gastrointestinal  onrial  is  to  l)o  tlior- 
oughly  unloaded  by  a  dose  of  castor  oil,  and  throughout  the  disease  this 
dose  is  to  be  repeated  every  three  or  four  days  to  prevent  intestinal  in- 
fection by  the  mucus  and  pus  which  have  been  coughed  up  and  swal- 
lowed. Warm  tub  baths  or  warm  sponge  baths  are  very  grateful,  and  serve 
a  useful  purpose  in  the  treatment  of  bronchitis.  They  quiet  the  nervous 
system,  promote  the  action  of  the  skin,  and  act  as  a  general  tonic.  Cold 
baths  and  cold  packs  are  not  indicated;  this  is  especially  true  in  infants 
under  eighteen  months  of  age.  Antipyretics  are  not  needed  to  reduce  the 
temperature.  Inunctious  of  guaiacol.  1  drachm  to  the  ounce  of  anhydrous 
lanolin,  should,  in  one-half-teaspoonful  doses,  be  thoroughly  rubbed  into 
the  skin  of  the  chest,  night  and  morning.  A  light  oilskin  jacket,  lined  with 
a  thin  layer  of  cotton-wool,  is  of  value,  and  is  especially  indicated  in  the 
infant  and  young  child  during  the  cold  winter  months  when  the  fresh-air 
treatment  is  being  given.  If  at  any  time  the  symptoms  indicate  that  a 
broncho-pneumonia  may  be  developing,  flaxseed  poultices  are  to  be  used  as 
directed  in  the  chapter  on  Bronchopneumonia. 

CHRONIC    BRONCHITIS 

Chronic  bronchitis  is  comparatively  rare  in  children.  The  only  form 
that  here  need  be  mentioned  is  the  asthmatic  bronchitis  previously  re- 
ferred to.  Its  treatment  may  require  carbonate  of  creosote,  syrup  of 
hydriodic  acid,  cod-liver  oil,  malt,  and  other  tonics.  A  warm,  equable 
climate  is  of  value. 

MEMBRANOUS   BRONCHITIS 

In  this  condition  the  mucous  membrane  of  the  trachea  and  bronchial 
tubes  is  covered  with  a  fibrinous  deposit.  It  is  comparatively  rarely  seen, 
except  in  diphtheria,  where  the  diphtheritic  membrane  may  extend  down 
into  the  bronchial  tree.  It  also  occurs  occasionally  in  croupous  pneumonia 
and  some  of  the  other  acute  infections.  The  symptoms  are  those  of  a 
severe  bronchitis,  and  the  diagnosis  is  made  on  the  expulsion  of  fibrinous 
casts. 

The  treatment  is  that  of  severe  bronchitis  in  addition  to  the  specific 
disease  which  produces  it. 


CHAPTEE    LI 

LOBAR    PNEUMONIA 
(Croupous  Pneumonia,  Fibrinous  Pneumonia) 

Etiology. — This  is  an  infiammation  of  the  lungs  which,  in  from  90 
to  95  per  cent,  of  the  cases,  is  caused  by  the  Frankel  diplococcus  pneu- 
moniae (pneumococcus).    It  is  believed  that  in  the  miajority  of  these  cases 


PATHOLOGY  443 

there  is  a  general  infection  with  the  pneumococcus,  and  that  the  pul- 
monary lesion  is  but  a  local  expression  of  a  general  constitutional  disease. 
From  this  viewpoint  we  may  class  the  disease  among  the  acute  infections. 
The  lungs  are  the  favorite  site  for  the  local  lesion,  because  the  pneumo- 
coccus commonly  finds  its  entrance  through  these  organs,  and  also  per- 
haps because  they  are  especially  susceptible  to  pneumococcic  inflamma- 
tions. Clinical  experience,  as  well  as  pathological  and  bacteriological  re- 
search, has  taught  us  that  it  is  better  to  consider  this  disease  from  the 
broad  viewpoint  of  a  general  infection,  and  as  such  we  shall  speak  of  it 
in  this  chapter.  It  should  be  remembered,  however,  that  the  same  croupous 
or  fibrinous  lesions  found  in  lobar  pneumonia  may  perhaps,  in  a  very 
small  percentage  of  cases,  l)e  jiroduced  l)y  organisms  (Friedlandcr's  bacillus, 
Pfeiffer's  bacillus,  and  streptococci)  other  than  pneumococci;  at  least  it 
may  be  said  that  pneumococci  have  not  been  found  in  these  cases,  and  again, 
on  the  other  hand,  it  should  be  noted  that  the  pneumococcus,  in  its  on- 
slaught upon  the  lungs,  is  associated  in  its  destructive  processes  with  strep- 
tococci, staphylococci,  the  Friedlander  bacillus,  and  other  organisms  which 
so  commonly  produce  secondary  infections. 

Exposure  to  damp  cold,  the  inhalation  of  irritating  particles,  and 
all  causes  that  produce  congestion  or  catarrhal  inflammation  of  the  respi- 
ratory passages  may  be  important  predisposing  causes  in  that  these  con- 
ditions incapacitate  the  mucous  membranes  for  resisting  the  pneumococcus. 
Influenza,  measles,  and  other  acute  infections  may  act  in  the  same  way. 
Croupous  pneumonia  is  comparatively  rare  during  the  first  six  months  of 
life,  but  is  very  common  from  that  time  to  the  end  of  the  second  year, 
and  is  comparatively  frequent  up  to  the  fifth  year.  It  is  more  common 
during  the  winter  and  spring,  and  occurs  with  equal  frequency  in  robust 
and  feeble  children. 

Pathology. — The  most  important  pathological  condition  is  the  pneu- 
mococcic septicemia.  The  pneumococcus  may  be  demonstrated  in  the  blood 
in  most  of  these  cases,  and  it  is  found  in  the  pulmonary  lesions  in  nearly 
all  cases  that  come  to  post-mortem  examination.  In  fatal  cases  it  is  com- 
monly associated  with  streptococci,  staphylococci,  or  other  organisms. 
The  pulmonary  lesions  do  not  occur  so  early  and  are  not  so  frank 
and  apparent  as  in  the  adult."  But  the  pulmonary  lesion,  when  it  does 
occur,  is  similar  to  that  of  the  adult  and  therefore  requires  no  detailed 
description  here.  The  pulmonary  inflammation  in  lobar  pneumonia  be- 
gins in  the  lung  tissue  and  not  in  the  small  bronchi  as  in  bronchopneumonia. 
It  spreads  more  or  less  rapidly  through  the  lung  by  continuity  of  sur- 
face, usually  confining  itself  to  one  lobe.  A  fibrinous  exudate  is  thrown 
out,  which,  with  tlie  otlier  inflammatory  products,  results  in  an  airless 
or  consolidated  condition  of  the  part  of  the  lung  affected.  The  inflam- 
matory lesion  passes  through  the  stages  of  congestion,  red  and  gray  hepati- 
zation and  resolution.  The  pleura  in  nearly  every  case  is  more  or  less 
involved,  usually  so  slightl}',  however,  as  not  to  affect  the  course  or 
prognosis  of  the  disease.    The  pleurisy  may  be  fibrinous,  serous  or  purulent 


444  LOBAR   PXEUMOXIA 

(empyema).  When  empyema  occurs  this  complication  becomes  the  dom- 
inant symptom  group,  greatly  exceeding  in  importance  and  danger  the 
original  condition. 

The  whole  or  part  of  one  lobe  may  be  involved,  or,  less  commonly, 
more  than  one  lobe  in  the  same  or  in  different  lungs  may  be  affected.  Very 
rarely  an  entire  lung  may  be  consolidated.  The  central  area  of  a  lobe  may 
be  involved  for  some  time  before  the  disease  reaches  the  surface  and  pro- 
duces physical  signs.  It  is  probable,  however,  that  most  of  these  so-called 
"central"  pneumonias  are  cases  of  general  pneumococcic  infection  in  which 
the  pulmonary  lesion  appears  as  a  late  manifestation.  The  pulmonary 
lesion  occurs  with  about  equal  frequency  in  the  right  upper  and  left  lower 
lobes;  in  about  two-thirds  of  the  cases  the  disease  begins  in  one  or  the 
other  of  these  sites.  The  left  upper  and  right  lower  lobes  are  affected 
with  about  equal  frequency,  the  disease  occurring  in  these  locations  about 
half  as  frequently  as  it  does  in  the  right  upper  and  left  lower  lobes.  Much 
less  commonly,  the  right  middle  lobe  is  the  first  part  of  the  lung  to  be 
affected.  The  statistics  of  different  writers  vary  somewhat  with  reference 
to  the  frequency  of  the  involvement  of  the  right  upper  and  the  left  lower 
lobes ;  in  infants  the  right  upper  lobe  is  more  frequently  involved,  in  chil- 
dren the  left  lower  lobe  is  the  favorite  site. 

Symptomatology. — General  Symptoms. — Within  a  few  hours  the  child 
presents  the  appearance  of  being  acutely  ill ;  it  is  feverish,  dull,  listless,  and 
gives  little  heed  to  its  surroundings.  In  older  children  a  distinct  rigor, 
followed  by  a  sudden  elevation  of  temperature  and  pain  in  the  side,  may 
call  attention  to  the  lungs  as  the  site  of  the  disease,  and  soon  these  symp- 
toms may  be  followed  by  cough,  and  later  by  rusty  sputum  and  the  physi- 
cal signs  of  acute  lobar  pneumonia.  We  are  here  interested,  however,  more 
especially  with  the  symptoms  of  this  disease  as  it  appears  in  the  infant  and 
young  child,  in  whom  the  early  symptom-complex  is  very  different.  The 
chill  is  rarely  present;  a  convulsion  may  occasionally  take  its  place,  or, 
with  the  sudden  rise  in  temperature,  the  child  may  feel  chilly,  have 
cold  extremities,  and  its  face  show  a  pinched  expression.  With  the  sudden 
onset  of  acute  symptoms,  the  evidences  of  a  severe  acute  intoxication  are 
well  marked;  there  is  high  fever  and  the  infant  is  dull,  stupid,  more  or 
less  prostrate,  and  is  little,  if  at  all,  interested  in  its  food  or  toys ;  anorexia, 
to  the  extent  of  absolutely  refusing  food,  is  common,  but  thirst  is  in- 
creased. Cough  and  pain  in  the  side  are  not  usually  present  during  the 
first  days  of  the  disease.  Vomiting  is  an  early  and  common  symptom 
but  does  not,  as  a  rule,  persist  after  the  second  day.  Diarrhea  is  rather 
common  in  infancy,  but  constipation  is  more  frequent  in  older  children. 
Associated  with  the  high  fever,  which  may  reach  104°  or  105°  F.  in  the 
first  twenty-four  hours,  there  is  a  rapid  increase  of  frequency  in  both  the 
respiration  and  pulse,  but  marked  dyspnea,  with  flaring  of  the  nostrils 
and  retraction  of  the  lower  part  of  the  chest,  is  not,  as  it  is  in  broncho- 
pneumonia, an  early  and  prominent  symptom.  The  normal  ratio  be- 
tween the  pulse  and  respiration  is  disturbed;  this  is  a  very  valuable  early 


SYMPTOMATOLOGY 


445 


syniptom.  Tlie  respiration  commonly  ranges  from  50  to  70,  and  the  pulse 
from  140  to  160;  the  respiration-pulse  ratio  is  thereby  increased  from 
the  normal  1  to  4,  to  1  to  2 1^  or  3;  later  in  the  disease  this  ratio  may 
be  as  1  to  2.  On  the  second  or  third  day  there  is  more  or  less  cough, 
and  the  characteristic  expiratory  grunt  may  be  associated  with  slight 
dyspnea,  which  tends  to  confirm  the  diagnosis  and  stimulate  the  physician 
to  a  careful  search  of  the  chest  for  the  earliest  physical  signs  associated 
with  the  piilmonary  lesion.  The  fever  continues  high  for  from  five  to 
eight  days,  and  is  perhaps  during  this  time  more  sustained  than  in  any 
other  disease  of  early  childhood.  As  the  physical  signs  in  many  cases 
appear  late,  the  diagnosis  must  be  made  or  at  least  suspected  by  the  general 


DAY 
OF  MONTH 

25 

26 

27 

28 

29 

30 

31 

1 

2 

3 

4 

5 

6 

7 

8 

9 

DAY 
OF  DISEASE 

1 

2 

3 

4 

5 

6 

7 

8 

9 

to 

II 

12 

13 

14 

15 

IB 

107° 
106° 

105° 
S    104' 

3 

£    103° 

Q. 

5    102* 

u    101° 

I 

i  100° 

^     99° 
98° 
97° 

/ 

^ 

^ 

r 

'^ 

\ 

f 

V 

\/ 

1 

1 

1 

\ 

/ 

i 

1 

/^ 

A 

rt 

1 

V 

\ 

/ 

s 

r 

> 

V 

U 

s/ 

s 

V 

PUtSE 

? 

? 

s 

s 

S 

? 

§ 

s 

1 

§ 

s 

s 

; 

? 

s 

? 

o 

£ 

t 

; 

§ 

? 

s 

? 

$ 

s 

s 

s 

s 

s 

s 

RESPIRATION 

2 

!l 

? 

s 

» 

« 

« 

t 

s 

s 

1 

? 

2 

s 

2 

C 

: 

; 

I 

s 

? 

- 

s 

- 

; 

- 

- 

g 

a 

«> 

; 

' 

Fig.  70. — Lobar  Pneumonia;  Child  Two  Years  of  Age. 


sj^mptom-complex  as  above  outlined.  The  sudden  onset,  with  high  and 
sustained  fever,  the  marked  constitutional  depression  with  listlessness  and 
sometimes  stupor,  the  disturbance  in  the  pulse-respiration  ratio,  the  cough, 
the  slight  dyspnea,  and  the  expiratory  grunt  are  usually  sufficient  to  make 
a  tentative  diagnosis  of  pneumonia. 

Fever. — In  the  great  majority  of  cases  the  temperature  rises  suddenly 
so  that  within  the  first  twenty-four  or  thirty-six  hours  it  may  reach  105° 
or  106°  F.  It  continues  high,  fluctuating  slightly,  until  the  crisis  occurs 
on  or  about  the  seventh  day.  At  this  time  it  is  not  unusual  for  the  tem- 
perature to  fall  within  twelve  or  twenty-four  hours  from  105°  F.  to  below 
normal,  and  with  this  fall  there  is  a  rapid  decrease  in  the  pulse  and 
respiration.    This  subnormal  temperature  may  continue  for  a  day  or  two. 


446 


LOBAE   PNEUMOXIA 


or  it  may  be  varied  by  slight  elevations  Ijefore  it  becomes  normal.  An 
uninterrupted  reeoverv  commonly  follows.  In  not  every  case,  however, 
is  this  typical  temperature  curve  observed,  irregularities  of  various  kinda 
being  possible.  In  a  minority  of  cases  the  fever  falls  by  lysis  with  sharp 
variations  in  the  temperature  until  it  finally  reaches  normal.  Abortive 
cases  occur  in  which  the  fever  may  continue  high  for  two  or  three  days,  and 
then  suddenly  fall  to  normal.  In  other  instances  the  fever  may  be  pro- 
longed, with  irregularities,  or  even  short  intervening  normal  periods,  for 
two  or  three  days;  these  cases  are  sometimes  spoken  of  as  relapsing  pneu- 
monias. They  represent  those  cases  in  which  there  is  an  extension  of  the 
pneumonic  process  to  other  parts  of  the  lung  after  the  focus  of  primary 
pulmonary  inflammation  has  almost  or  quite  run  its  course. 


DAY 
OF   MONTH 

3 

4 

5 

6 

7 

8 

9 

10 

II 

12 

13 

14 

IS 

DAY 
or  DISEASE 

1 

i 

3 

4 

5 

6 

7 

8 

9 

10 

II 

12 

13 

107° 

106° 
105' 

U                       r, 

a.     104 

3 
H 

g     103° 
a. 

1    102' 

t 

^   lor 

z 
ill 

J     100° 

< 

IL 

90" 
98' 
97° 

A 

r 

^ 

\ 

sl 

\ 

1 

\ 

\\ 

\ 

\ 

V 

V 

\ 

\ 

V 

1 

! 

i 

L 

\ 

\ 

\ 

IaI 

v^. 

v 

^ 

SI 

|S 

s/ 

PULSE 

1 

° 

t, 

h 

% 

? 

? 

5 

s 

' 

g 

s 

% 

h 

s 

; 

1 

1 

% 

1 

1 

1 

1 

' 

1 

RESPIRATION 

s 

to 

% 

» 

' 

« 

« 

? 

" 

' 

' 

o 

% 

s 

; 

s 

£ 

s 

£ 

g 

<C 

% 

t 

s 

Fig.  71. — Lobar  Pneumonia;   Child  Four  Years  of  Age. 

Bespiration. — This,  as  previously  noted,  is  accelerated  out  of  propor- 
tion to  the  increase  in  the  pulse  rate.  It  commonly  varies  between  40  and 
80 ;  the  younger  the  infant  the  more  rapid  the  respiration.  The  tachypnea 
or  rapid  breathing,  however,  in  this  disease  is  associated  with  comparatively 
little  dyspnea,  and  in  this  it  differs  markedly  from  bronchopneumonia. 
In  some  cases,  however,  as  the  disease  progresses,  the  accessory  muscles  of 
respiration  are  brought  into  play  and  flaring  of  the  nostrils  is  noted,  but 
the  marked  drawing  in  of  the  chest  at  the  diaphragmatic  groove,  which  is 
so  characteristic  of  bronchopneumonia,  is  slight  or  not  at  all  present. 
The  pause,  however,  which  occurs  at  the  end  of  inspiration,  followed  by 
shallow  expiration,  and  associated  with  an  expiratory  grunt,  is  very  char- 
acteristic of  lobar  pneumonia. 


SY^[PTO]krATOLOr.Y 


447 


Cough. — During  the  first  day  or  two  cough  may  be  entirely  absent, 
but  sooner  or  later  it  becon:es  a  noticeable  symptom,  not  infrequently  as- 
sociated with  pain  in  the  side  or  abdomen.  The  cough  is  one  of  the  last 
symptoms  to  disappear  and  is  not  infrequently  more  pronounced  during 
convalescence  than  during  the  height  of  the  fever.  Sputum  is  difficult 
to  obtain,  as  young  children  do  not  expectorate.  Occasionally,  however, 
specimens  may  be  secured  when  the  child  vomits,  or  cough  may  be  ex- 
cited by  introducing  a  gauze-wrapped  finger  into  the  pharynx,  and  wiping 
up  the  sputum  as  it  is  brought  up  in  this  way.  Sputum  thus  obtained 
may  present  the  typical  rusty  appearance,  and  pneumococci  in  great  num- 
bers may  be  demonstrated  in  it. 


DAY 

OF    MONTH 

4 

5 

6 

7 

8 

9 

10 

II 

12 

13 

14 

IS 

16 

17 

18 

19 

DAY 

OF  OrSEASE 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

II 

12 

13 

14 

15 

16 

107- 

106' 

105' 

S     104° 

2    103° 
a 

it    102° 

H 

u     101° 

z 
u 

=  too 
2 

99' 
98 
97° 

\ 

A 

\/ 

^ 

A 

\ 

1 

V 

^ 

V 

•J 

V 

^ 

v 

^ 

A 

, 

\j 

1 

\ 

i 

li 

V 

V 

\ 

1 

\ 

\ 

1 

\/ 

PULSE 

S 

1 

s 

c 

? 

s 

g 

s 

s 

c 

i 

5 

? 

;  s 

; 

t 

s 

s 

i 

« 

? 

? 

? 

t 

; 

s 

S 

s 

te 

RESPIRATION 

; 

; 

; 

; 

» 

; 

? 

w 

ft 

s 

s 

5 

(0 

?  s 

s 

1 

s 

g 

S 

; 

S 

s 

S 

^ 

g 

£ 

s 

s 

s 

Fig.  72. — Lobar  Pneumonia;  Child  Ten  Years  op  Age. 

The  Blood. — Blood  cultures  will,  in  the  great  majority  of  cases, 
demonstrate  the  presence  of  the  pneumococcus,  but  this  procedure  is  not 
necessary  or  justifiable  for  routine  diagnosis.  A  well-marked  polynuclear 
leukocytosis  is  present,  which  may  reach  from  40,000  to  50,000  to  the 
cubic  m.  m.  A  high  leukoc}i;e  count  is  a  favorable  indication,  while  a 
low  leukocyte  count,  with  well-marked  physical  signs  of  lobar  pneumonia, 
is  an  unfavorable  sign. 

Urine. — The  urine,  in  many  of  these  eases,  contains  a  trace  of  albumin 
with  occasional  hyalin  and  granular  casts.  This  febrile  or  toxic  albuminuria 
is  of  comparatively  little  significance  as  it  disappears  shortly  after  the 
crisis.    Acute  nephritis  may  occur  as  a  rare  complication. 

Physical  Signs. — In  examining  the  chest  of  infants  and  young  chil- 
dren the  physician  must  keep  in  mind  the  fact  that  the  inspiratory  sounds 
30 


448  LOBAl?    PNEUMONIA 

at  this  period  of  life  are  loud  aud  coarse  iii  quality,  and  that  this  is  es- 
pecially noticeable  on  the  right  side,  beneath  the  clavicle  and  over  the 
spine  of  the  scapula.  This  normal  puerile  breathing  may  easily  be  mis- 
taken for  bronchial  or  tubular  breathing,  such  as  is  found  in  pneumonia. 
The  physical  signs  of  pneumonia  in  infancy  are  similar  to  those  occurring 
in  the  adult,  but  they  not  infrequently  appear  so  late  that  they  are  of 
little  value  in  the  early  diagnosis  of  this  disease,  and,  in  some  instances, 
they  may  never  be  discovered  or  they  may  be  so  evanescent  as  to  be 
misleading.  These  facts,  however,  only  make  it  more  imperative  that  the 
physician  should  carefully  search  the  chest,  day  after  day,  in  all  suspected 
cases. 

Peraassion. — It  is  important  to  remember  that  light  percussion  may 
disclose  small  areas  of  dullness  where  strong  percussion  fails.  In  the 
early  diagnosis  of  croupous  pneumonia,  however,  percussion  is  little  to 
be  relied  upon,  but  as  consolidated  areas  appear  they  may  be  discovered, 
and  in  advanced  cases  the  dullness  may  be  well  marked  over  one  or  more 
lobes  of  the  lungs. 

Auscultation. — Auscultation  is  of  great  value.  By  it  one  may  sooner  or 
later  discover  crepitant  and  subcrepitant  rales,  the  most  valuable  of  all 
physical  signs.  These  are  commonly  heard  at  the  base  or  apex  of  the  lungs ; 
sometimes  they  are  first  heard  in  the  axillary  region;  the  whole  lung 
should,  day  after  day,  be  carefully  searched  for  them.  Bronchophony  is 
an  early  and  valuable  physical  sign,  and  bronchial  breathing  may  later 
be  made  out  over  the  consolidated  lung.  Coughing,  and  crying,  by  pro- 
ducing deep  inspirations,  may  serve  to  bring  out  or  make  the  auscultatory 
signs  more  pronounced. 

Complications. — Pleurisy  is  the  most  common  complication.  In  most 
instances  it  adds  to  the  discomfort  rather  than  to  the  seriousness  of  the 
disease.  In  a  small  minority  of  the  cases,  however,  instead  of  a  simple 
fibrinous  or  mild  serous  pleurisy,  we  have  a  complicating  empyema,  which 
at  once  becomes  the  most  serious  feature  of  the  disease.  In  every  instance, 
where  delayed  convalescence  is  associated  with  an  intermittent  fever,  em- 
pyema should  be  suspected  and  carefully  searched  for.  Otitis  media  is 
a  common  complication.  Meningitis  is  a  rare  complication,  but  meningism 
is  not  uncommon.  Arthritis,  peritonitis,  pericarditis,  endocarditis,  osteomy- 
elitis, abscess  of  the  liver,  and  diseases  of  the  accessory  sinuses  of  the  nose 
are  possible  complications,  all  of  which  may  be  excited  by  the  pneumo- 
coccus.  Bronchopneumonia  is  a  common  and  very  dangerous  complica- 
tion in  children  under  two  years  of  age,  but  it  is  more  often  seen  in  hos- 
pital than  in  private  practice.  Pneumonia  occurring  in  tuberculous  chil- 
dren may  be  prolonged  and  may  develop  into  an  active,  advancing 
pulmonary  tuberculosis. 

Splanchnic,  or  vasomotor,  paralysis,  as  Romberg  and  Piissler  have 
shown,  may  result  from  the  action  of  pneumococcus  toxins  on  the  vaso- 
motor center.  In  this  condition  the  blood  is  withdrawn  from  the  heart 
and  the  general  circulation  into  the  dilated  veins  of  the  splanchnic  area. 


TREATMENT  449 

and  the  heart,  because  of  the  scarcity  of  blood,  becomes  feeble  and  ir- 
regular in  action,  and  death  may  result.  This  condition  occurs  only 
when  there  is  a  profound  general  pneuraococcus  infection. 

Differential  Diagnosis. — In  some  cases  vomiting,  slight  intestinal  dis- 
turbance, fever,  and  general  toxemia  may  suggest  a  gastrointestinal  in- 
toxication, but  since  a  laxative  with  abstinence  from  food  makes  little 
or  no  impression  upon  the  fever  and  constitutional  symptoms,  intestinal 
toxemia  may  thereby  be  quickly  eliminated.  In  some  cases  the  vomiting, 
the  stupor,  the  delirium,  the  rigidity  of  the  muscles  of  the  neck  and  upper 
part  of  the  back,  to  whicli  may  be  added  a  certain  degree  of  opisthotonos, 
very  strongly  suggest  meningitis.  These  symptoms,  however,  come  on 
slowly,  so  that  by  the  time  the  meningeal  syndrome  is  closely  simulated 
one  can,  as  a  rule,  find  the  physical  signs  of  pneumonia  in  the  lungs.  In 
other  cases  the  vomiting,  abdominal  pain  and  distention,  tenderness,  and 
slight  resistance  on  the  right  side  over  the  head  of  the  colon  may  strongly 
suggest  appendicitis ;  many  such  cases  have  been  operated  upon.  The  well- 
known  tendency  of  the  child  to  refer  thoracic  pain  to  the  abdomen  makes 
the  danger  of  mistaking  a  pneumonia  for  an  appendicitis  more  probable. 
Griffith  says:  "The  distinction  is  to  be  made  by  giving  due  consideration 
to  (1)  the  sudden  rise  of  temperature  to  103°  F.  or  thereabouts,  and  the 
tendency  to  maintain  this  degree;  (2)  the  acceleration  of  respiration,  which 
is  out  of  proportion  to  the  pulse  rate  or  pyrexia;  (3)  the  relaxation  of 
the  abdominal  walls  between  the  respirations;  (4)  the  diminution  or  the 
disappearance  of  tenderness  on  deep  pressure  with  the  fiat  of  the  hand; 
(5)  the  possible  presence  of  cough.  Finally  no  operation  for  appendicitis 
should  ever  be  performed  until  after  a  careful  or  perhaps  repeated  ex- 
amination of  the  lungs  has  been  made."  For  the  further  differential 
diagnosis  see  Bronchopneumonia. 

Prognosis. — The  prognosis  in  uncomplicated  lobar  pneumonia  in  the 
infant  and  young  child  is  vastly  better  than  it  is  in  the  adult.  The  great 
majority  of  these  eases  get  well,  and  there  is  perhaps  no  serious  disease 
of  infancy  and  childhood  in  which  the  convalescence  is  so  rapid  and  so 
satisfactory.  Following  the  crisis  the  child  improves  so  rapidly  that  it 
is  difficult  to  keep  him  in  bed  for  the  seven  to  ten  days  necessary  to  in- 
sure satisfactory  convalescence.  The  younger  the  infant  the  more  un- 
favorable the  prognosis,  so  that  in  infants  under  one  year  of  age,  es- 
pecially where  there  is  well-marked  consolidation  of  the  lung  with  high 
fever  and  rapid  respirations,  it  is  well  to  give  a  guarded  prognosis,  since 
a  considerable  percentage  of  these  cases  end  fatally.  In  general  terms 
it  may  be  said  that  in  infancy  the  death  rate  is  from  10  to  20  per  cent., 
and  in  children  from  3  to  6  per  cent.;  the  lower  figures  in  each  case 
refer  to  children  treated  under  favorable  hygienic  conditions  in  their  own 
homes. 

Treatment.— It  should  be  remembered  that  lobar  pneumonia  is  a  self- 
limited  disease  for  which  we  have  no  specific  and  in  which  we  may  do  great 
harm  by  over-medication.     The  treatment  must  be  largely  hygienic  and 


450  LOBAR    PXEUMOXIA 

sustaining,  and  even  the  symptomatic  treatment  which  is  indicated  at 
ever3^  stage  must  not  be  overdone. 

Hygiexic  Treatmext. — The  hygiene  of  the  sick  room  is  all-important. 
The  child  should  be  put  to  bed  in  a  large,  bright  room,  under  the  care  of 
a  trained  nurse,  instructed  to  keep  the  room  quiet  and  free  from  unneces- 
sar}^  visitors.  The  most  important  agent  is  fresh  air.  This  fact  was  long 
ago  emphasized  by  Northrup,  who  has  continued  for  the  past  ten  years  to 
be  the  most  ardent  advocate  of  the  fresh  air  treatment  not  only  of  pneu- 
monia, but  of  many  other  acute  diseases;  as  he  says,  the  air  in  the  room 
"should  be  fresh,  cool,  and  flowing."  In  other  words,  the  patient  is  to  be 
in  a  room  with  windows  open  night  and  day,  even  though  the  temper- 
ature in  the  room,  during  the  winter  months,  falls  as  low  as  60° F.;  with 
proper  indoor  heating  apparatus  the  room  may  be  kept  at  a  temperature  of 
60°  to  65° F.,  with  fresh,  cool,  "flowing  air"  coming  in  through  two  or 
more  windows.  In  carrying  out  this  treatment  it  is  evident  that  not  only 
the  garments,  but  the  bed-clothing,  of  the  child  should  be  adapted  to  the 
temperature  of  the  room.  The  body  of  the  child  must  be  kept  com- 
fortably warm,  while  it  is  breathing  the  fresh,  cool  air.  If  necessary,  hot 
water  bottles  and  warm  blankets  should  be  used  on  very  cold  days.  The 
nurse  on  duty  in  such  a  room  should  dress  to  protect  herself  from  the 
cold.  When  this  ^treatment  was  coming  into  vogue,  a  number  of  years 
ago,  the  physician  found  it  difficult  to  overcome  the  prejudice  against 
"catching  cold,"  but  the  success  of  the  outdoor  or  fresh  air  treatment  of 
this  disease  has  been  so  clearly  demonstrated  in  the  last  ten  years  that 
the  laity  have  now  come  to  accept  it  without  protest. 

Dietetic  Treatment. — The  importance  of  the  dietetic  treatment  is 
emphasized  by  the  fact  that  gastric  and  intestinal  disturbances  are  com- 
mon, and  that  anorexia  is  often  so  pronounced,  that  the  child  refuses  all 
food;  in  the  face  of  these  conditions  the  physician  is  called  upon  to  com- 
bat, with  proper  food  and  nourishment,  an  exhausting  disease,  which  may 
run  for  a  week  or  more  with  high  fever,  and  severe  toxic  s}Tnptoms.  In- 
fants and  young  children  can  usually  be  induced  to  take  a  moderate  amount 
of  liquid  foods,  such  as  modified  milk,  beef  juice,  meat  broths  and  egg 
albumin;  it  is  important,  however,  that  these  foods  should  not  be  given  at 
such  short  intervals,  and  in  such  quantities,  that  the  weakened  digestive 
capacity  of  the  infant  will  be  overtaxed,  and  intestinal  fermentation  with 
gaseous  distention  be  thereby  produced.  In  underfed  infants  whiskey  or 
brandy  is  indicated  from  the  beginning  of  the  disease.  In  my  experience, 
good  rye  whiskey  acts  better  than  brandy;  when  mixed  with  water  and 
a  little  sugar  it  is  readih^  taken,  and  produces  no  gastrointestinal  disturb- 
ance; where  the  carbohydrate  intake  is  small  whiskey  acts  as  a  food 
rather  than  as  a  stimulant,  and  thereby  furnishes  energy  to  the  cells  and 
prevents  emaciation  and  loss  of  strength.  It  is  my  custom  to  give  to 
infants,  between  one  and  two  years  of  age,  20  or  30  drops  three  or  four 
times  in  the  tAventy-four  hours;  this  dose  may  be  increased  with  increas- 
ing toxemia  and  prostration. 


TEEATMENT  451 

Cool  water  to  drink  and  i)lonty  of  it  was  long  ago  recommended  in 
the  treatment  of  pneumonia,  ^^^^ile  these  children  have  little  or  no  ap- 
petite, they  are  thirsty,  and  will  drink  a  large  quantity  of  cool  water, 
the  intake  of  which  helps  to  reduce  the  fever  and  to  diminish  the  toxemia, 
as  it  promotes  the  excretion  of  toxins  through  the  skin  and  kidneys. 

Local  Applications. — Poultices  and  oil  silk  jackets  encasing  the 
chest  are  not  indicated  in  this  form  of  pneumonia.  Hot  water  bottles, 
electric  pads,  small  poultices  and  mustard  plasters  may  be  used  for  the 
relief  of  the  pleuritic  pain,  when  it  is  severe  enough  to  interfere  with  sleep. 
Mustard  plasters,  which  are  so  universally  recommended  as  counter- 
irritants,  should  be  strong  enough  to  produce  only  redness  of  the  skin 
without  blistering;  two  parts  of  flour  and  one  part  of  mustard  made  into 
a  paste  and  spread  between  two  layers  of  gauze  may  be  used  for  this  pur- 
pose. I  have  rarely  found  it  necessary  to  use  counter-irritation  in  the 
treatment  of  lobar  pneumonia  in  children.  Priessnitz's  applications  are 
of  great  value  when  the  fever  is  high  and  the  respirations  rapid.  They 
are  applied  by  dipping  a  piece  of  light  flannel  in  w^ater  (temperature 
about  70°F.),  wringing  it  out,  applying  it  to  the  entire  chest  of  the  child, 
and  covering  it  with  a  dry  flannel.  The  wet  flannel  may  be  changed  from 
every  half  hour  to  three  hours,  as  the  symptoms  demand. 

Antipyretics. — It  is  most  important  that  the  physician  should  not 
center  his  attention  upon  the  high  temperature  and  attempt  to  beat  it 
down  with  cold  water  and  other  antipyretics.  A  temperature  of  lOSVo" 
or  104°r.  in  lobar  pneumonia,  as  a  rule,  does  not  require  antipyretics; 
hyperpyrexias  of  105°  and  106°F.,  however,  demand  treatment.  The  use 
of  baths  for  the  reduction  of  temperature  will  depend  altogether  upon  the 
manner  in  which  the  individuail  case  responds  to  this  treatment.  If  the 
high  temperature  is  associated  with  marked  nervous  symptoms  and  other 
evidences  of  profound  toxemia,  hydrotherapy  will,  in  the  great  majority 
of  cases,  give  great  relief,  not  only  by  reducing  the  temperature,  but  also 
by  quieting  the  nervous  symptoms  and  stimulating  nutritional  processes. 
If  such  a  favorable  result  follows  the  use  of  the  bath,  it  may  be  used  as 
indicated  throughout  the  course  of  the  disease.  Many  cases  suffering  from 
nervous  symptoms  and  severe  toxemia  are  benefited  by  a  hot  tub  bath  twice 
in  twent}-four  hours,  but  when  these  symptoms  are  associated  with  high 
temperatures  sponging  with  alcohol  and  water,  or  what  is  miich  more 
effective,  the  cold  pack,  may  be  resorted  to  three  or  four  times  in  twenty- 
four  hours.  In  giving  the  cold  pack,  the  body  of  the  child  should  be 
wrapped  in  a  bath  towel  wrung  out  of  cold  water,  and  over  this  a  light 
dry  blanket  should  be  wrapped.  The  towel  may  be  removed  after  one- 
half  hour  and  the  child  sponged  off  with  alcohol  and  warm  water.  Ice- 
caps may  be  applied  to  the  head  with  benefit,  especially  in  those  cases  with 
high  temperature  and  pronounced  nervous  symptoms. 

The  coal-tar  antipyretics  are  almost  universally  condemned  by  writers 
upon  this  subject,  and  yet  they  are  almost  universally  used  by  the  general 
practitioner,  and  I  am  inclined  to  believe,  from  my  own  experience,  that 


452  LOBAK    PXEU^fOXIA 

in  certain  cases  of  high  temperature  with  pronounced  nervous  symptoms 
phenacetin  may  be  used  to  advantage,  especially  in  older  children.  There 
is  no  question  as  to  the  sedative  and  antipyretic  action  of  this  drug.  It 
will  ofttimes  produce  a  quiet  sleep  by  relieving  headache  and  other  pain, 
and  I  am  of  the  belief  that  the  sleep  thus  produced  does  more  good  than 
the  depressing  effect  of  the  phenacetin  can  do  harm.  Under  two  years  of 
age  this  drug  should  not  be  used,  but  in  older  children  it  is  to  be  recom- 
mended, not  as  an  antipyretic,  but  occasionally  to  relieve  the  pain,  rest- 
lessness and  nervousness,  which  prevent  sleep. 

Medical  Treatment. — With  the  onset  a  cathartic  should  be  given. 
Castor  oil  is  to  be  preferred,  if  nausea  and  vomiting  do  not  prohibit  its 
use;  if  castor  oil  is  contraindicated,  calomel  should  be  given,  followed  by 
a  dose  of  Bochelle  salts.  Throughout  the  course  of  the  disease  the  gastro- 
intestinal tract  should  be  carefully  watched  and  cathartic  medication  re- 
sorted to,  to  prevent  abdominal  distention,  to  overcome  constipation,  and 
to  clear  the  canal  of  fermenting  food  stuffs,  which  may  be  adding  an 
intestinal  toxemia  to  the  existing  disease;  this  is  especially  important  in 
infants  and  young  children.  Care  should  be  exercised  that  this  laxative 
treatment  be  resorted  to  only  when  necessary,  as  harm  may  result  from 
unnecessary  catharsis. 

Quinin  is  a  remedy  of  value  in  the  routine  treatment  of  pneumonia 
in  children  over  two  years  of  age.  It  should  be  given  in  the  form  of 
euquinin  to  young  children,  and  in  the  form  of  the  sulphate  or  bisulphate 
to  older  ones.  The  disagreeable  taste  of  this  drug  is  a  rather  serious  ob- 
jection to  its  administration  in  a  disease  in  which  so  much  depends  upon 
the  giving  of  proper  foods  and  stimulants,  and  its  greatest  value,  there- 
fore, is  in  children  who  are  old  enough  to  take  it  in  capsule  form.  The 
vaccine  treatment  is  contraindicated  in  acute  forms  of  pneumonia.  In 
the  chronic  forms,  however,  which  are  occasionally  seen  in  older  children, 
an  autogenous  vaccine,  or  the  pneumococcus  stock  vaccine,  may  be  used  at 
times  with  great  advantage  as  directed  under  vaccine  therapy.  The  use 
of  antitoxic  serums  has  not  been  followed  by  appreciably  good  results. 
Carbonate  of  guaiacol  or  creosote  may  be  given  internally,  but  their  value 
when  administered  in  this  way  is  so  problematical  that  it  is  much  better 
to  administer  guaiacol  by  inunction.  One  drachm  of  liquid  guaiacol  when 
thoroughly  incorporated  with  1  ounce  of  anhydrous  lanolin  may,  as  a 
routine  measure,  be  administered  night  and  morning,  by  inunction  in 
y<2r  or  1-drachm  doses,  as  recommended  in  the  chapter  on  Therapeutics  of 
Infancy  and  Childhood. 

Tincture  of  strophanthus  is,  in  my  opinion,  the  most  valuable  stim- 
ulant we  have  in  this  disease.  I  have  used  it  as  a  matter  of  routine  treat- 
ment in  every  case  of  pneumonia  which  I  have  seen  in  the  last  fifteen 
years.  I  do  not  believe  that  it  is  contraindicated  in  the  beginning,  or  that 
it  should  be  given  only  when  cardiac  failure  commences.  To  infants 
between  one  and  two  years  of  age  one  drop  should  be  given  every  four 
to  six  hours;  between  three  and  four  years,  two  drops.    As  the  disease  ad- 


TKEATMEXT  453 

vances,  this  dose  may  be  doubled  in  frequency  rather  than  in  size,  so  that 
a  child  of  two  years,  as  it  approaches  the  crisis,  will  be  taking  two  drops 
every  two  or  three  hours.  In  severe  cases,  where  the  toxemia  is  great  and 
the  respirations  rapid,  sulphate  of  strychnin  is  a  valuable  respiratory  stim- 
ulant and  general  tonic;  for  a  child  two  years  of  age  1/150  of  a  grain 
may  be  given  with  whiskey  at  three-  or  four-hour  intervals,  or  1/300  of  a 
grain  may  be  given  hypodermically  at  six-hour  intervals.  Caffein-sodium- 
benzoate  or  salicylate  (in  1-grain  doses  by  mouth,  or  i/2-grain  doses  hypo- 
dermically, for  a  child  four  years  of  age)  is  one  of  the  most  valuable  cir- 
culatory stimulants.  It  is  indicated  in  severe  general  pneumococcic  tox- 
emia, in  which  there  is  danger  of  vasomotor  paralysis.  It  should  always 
be  used  if  the  pulse  becomes  feeble  and  intermittent. 

Oxygen  is  a  valuable  respiratory  stimulant,  but  the  indications  for  its 
use  have  been  greatly  diminished  by  the  fresh-air  treatment  of  this  disease; 
it  may,  however,  be  used  in  tiding  desperate  cases  over  the  crisis;  it  is 
indicated  when  the  respirations  are  very  rapid  and  cyanosis  is  marked. 
Nitroglycerin  is  also  recommended  in  threatened  collapse ;  1/300  of  a  grain 
may  be  given  hypodermically  to  a  child  three  years  of  age.  As  previously 
noted,  whiskey  in  large  doses,  1  or  2  drachms,  may  be  used  as  a  stim- 
ulant and  to  counteract  the  toxemia  in  severe  cases. 

Sedatives  other  than  the  bromids  and  belladonna  have  no  place  in 
the  treatment  of  pneumonia  in  infancy.  For  children  between  the  age  of 
one  and  two  years,  three  or  four  grains  of  bromid  of  potash  and  one 
minim  of  tincture  of  belladonna  may  be  given  at  three-  or  four-hour  in- 
tervals, to  allay  the  cough  and  nervousness.  These  drugs  should  be  given 
in  some  palatable  vehicle,  such  as  the  elixir  of  lactated  pepsin,  so  as  not 
to  irritate  the  child  or  disturb  the  stomach.  Opiates  are,  in  my  opinion, 
dangerous  drugs  in  the  treatment  of  the  pneumonias  of  infancy.  They 
are  rarely,  if  ever,  indicated  under  two  years  of  age.  In  older  children, 
between  three  and  five,  codein,  1/10  of  a  grain,  paregoric,  fifteen  or  twenty 
drops,  or  some  of  the  other  preparations  of  opium  may  occasionally  be 
indicated  to  relieve  the  pain  caused  by  the  cough  or  by  a  complicating 
pleurisy. 

Expectorants,  such  as  ammonia,  ipecac  and  squill  preparations,  are  con- 
traindicated,  since  by  disturbing  the  gastrointestinal  tract  they  do  more 
harm  than  good. 

Treatment  of  Convalescence. — The  only  treatment  commonly  neces- 
sary during  convalescence  is  to  keep  the  child  in  bed  for  a  week  and  let 
him  have  plenty  of  fresh  air  and  a  carefully  selected  nutritious  diet  within 
the  range  of  his  digestive  capacity.  If,  however,  the  child  does  not  rapidly 
regain  its  strength,  is  anemic,  and  has  little  appetite,  it  may  be  benefited  by 
such  tonics  as  malt  and  iron,  malt  and  cod-liver  oil,  syrup  of  the  iodid 
of  iron,  or  syrup  of  hydriodic  acid.  In  weak  children  and  those  predisposed 
to  tuberculosis,  creosote  or  the  benzoate  or  carbonate  of  guaiacol  may  be 
given  with  advantage. 


454  BEOXCHOPXEUMONIA 

CHAPTEE    LII 
BEONCHOPNEUMONIA 

Bronchopneumonia,  next  to  gastroenteritis,  is  the  most  common  of  the 
serious  disorders  of  infancy.  It  is  a  disseminated  and  lobular  inflammation 
of  the  lungs,  which  usually  follows  and  is  always  associated  with  a  bron- 
chitis of  the  smaller  bronchi.  It  is,  in  the  vast  majority  of  cases,  a  direct 
sequel  of  some  form  of  bronchitis.  The  many  causes  of  bronchitis  are, 
therefore,  its  more  or  less  direct  etiological  factors.  It  is  a  syndrome  rather 
than  a  distinct  disease,  in  which  the  pathological  processes  are  excited 
and  kept  up  by  a  variety  of  microorganisms.  The  pneumococcus,  which,  as 
has  been  previously  noted,  is  almost  the  sole  cause  of  lobar  pneumonia,  is 
the  exciting  cause  of  bronchopneumonia  in  a  considerable  number  of  cases. 
The  so-called  primary  cases  of  bronchopneumonia  occurring  in  infants,  are 
almost  all  due  to  this  organism,  and  should  properly  be  classified  with  the 
lobar  pneumonias  under  the  term  pneumococcic  infection.  There  are  many 
difficulties,  however,  in  adopting  such  a  classification  in  a  text-book.  The 
various  forms  of  pneumonia  have  for  generations  been  classified  according 
to  their  anatomical  findings,  and,  while  the  terms  lobar  and  bronchopneu- 
monia may  be  confusing,  and  actually  misleading,  in  the  light  of  the 
present-day  conception  of  these  diseases,  they  are  sanctioned  by  long  usage 
and  cannot,  in  the  present  state  ci'  our  knowledge,  be  replaced  by  a  prac- 
tical etiological  (bacteriological)  classification,  although  the  present  trend 
of  bacteriological  research  indicates  that  such  a  classification  may  be 
adopted  in  the  future.  It  is  better,  therefore,  from  the  standpoint  of  the 
clinician,  to  continue  to  use  the  terms  lobar  and  bronchopneumonia.  It 
is  to  be  understood  that  lobar  pneumonia  is  used  in  the  broad  sense  pre- 
viously described,  and  that  the  term  bronchopneumonia  is  used  to  mean  an 
inflammatory  process  of  the  lobules  and  of  the  smaller  bronchi,  from  what- 
soever cause  this  inflammation  may  be  produced.  This  gives  the  clinician 
an  opportunity  to  still  further  classify  his  bronchopneumonias,  not  only 
with  reference  to  the  age  and  physical  condition  of  the  child,  but  also 
with  reference  to  certain  more  or  less  definite  etiological  factors  which 
produce  variations  in  the  clinical  types  of  this  disease. 

Etiology. — Age  is  an  important  predisposing  factor.  Bronchopneu- 
monia is  comparatively  rare  during  the  first  few  months  of  life ;  it  is  most 
prevalent  during  the  second  six  months,  and  continues  to  be  very  common 
during  the  second  year;  thereafter  it  occurs  with  rapidly  decreasing  fre- 
quency up  to  the  sixth  year.  About  three-fourths  of  the  cases  occur  dur- 
ing the  winter  and  spring  months.  This  is  due  to  the  fact  that  the  acute 
infectious  diseases  and  bronchitis  are  more  prevalent  at  this  time.  Bad 
hygienic  surroundings  are  very  potent  etiological  factors.  This  disease  is 
found  very  much  more  frequently  in  hospitals,  institutions  for  children, 
and  tenement  houses    than  it  is  in  the  homes  of  the  well-to-do.     Gastro- 


PATHOLOGY  455 

intestinal  disorders,  glandular  tuberculosis  and  all  forms  of  malnutrition, 
especially  rickets,  may  predispose  to  bronchitis,  and  at  the  same  time  dim- 
inish the  natural  powers  of  resistance  of  the  infant,  so  that  a  bronchitis 
may  readily  develop  into  a  pneumonia.  Bronchopneumonia  usually  fol- 
lows a  simple  bronchitis  or  a  bronchitis  produced  by  measles,  influenza, 
pertussis,  diphtheria,  scarlet  fever,  or  some  other  acute  infection.  The 
bronchopneumonia  of  measles  occurs,  as  a  rule,  during  the  stage  of  erup- 
tion, but  is  not  infrequently  overlooked  until  the  eruption  has  subsided. 
Bronchopneumonia  occurs  as  a  complication  of  whooping-cough  during  the 
height  of  that  disease,  when  the  paroxysms  are  severe  and  the  resistance 
of  the  child  is  somewhat  reduced  by  the  long  siege  of  coughing.  It  is 
more  likely  to  occur  in  young  and  delicate  infants,  especially  in  those  who 
are  suffering  from  a  glandular  tuberculosis;  it  is  more  dangerous  than 
the  bronchopneumonia  following  measles.  Influenzal  bronchopneumonia 
may  be  due  to  the  influenza  bacillus,  unassisted  by  other  microorganisms; 
as  the  disease  progresses,  however,  secondary  infection  usually  occurs. 
True  influenzal  bronchopneumonia  is  comparatively  rare,  but  may  occur 
during  an  e2)idemic  of  this  disease;  it  is  more  prevalent  in  older  children 
than  in  infants.  The  bronchopneumonia  following  diphtheria  and  scarlet 
fever  is  usually  severe;  it  is  usually  a  fatal  complication  when  it  occurs 
in  cases  of  laryngeal  diphtheria,  following  intubation  or  tracheotomy.  The 
most  important  fact  to  keep  in  mind  concerning  the  secondary  broncho- 
pneumonias caused  by  the  acute  infections  is  that  they  are  nearly  always 
mixed  infections,  and  that  in  the  vast  majority  of  cases,  especially  in 
measles,  pertussis,  and  influenza,  these  bronchopneumonias  may  be  pre- 
vented by  fresh  air  and  proper  hygienic  surroundings,  and  may  be  produced 
by  confining  patients  suffering  from  these  acute  infections  in  close,  ill- 
ventilated  rooms,  and  especially  by  associating  them  with  other  children 
suffering  from  bronchopneumonia,  or  any  form  of  infection  in  which  the 
septic  cocci  are  causative  factors.  The  microorganisms  most  commonly 
associated  with  the  destructive  processes  in  bronchopneumonia  are  strep- 
tococci, staphylococci,  pneumococci,  Friedlander's  bacilli,  influenza,  typhoid, 
and  diphtheria  bacilli. 

Pathology. — The  important  difference  between  bronchopneumonia  and 
lobar  pneumonia  consists  in  the  primary  involvement  of  the  finer  bronchi 
in  the  former  disease,  while  in  the  latter  the  inflammatory  process  spreads 
more  or  less  rapidly  through  the  lung  tissue  without  the  intervention  of 
a  catarrhal  inflammation  of  the  finer  bronchi.  From  this  it  would  appear 
that  in  I)ronchopneumonia  the  infectious  agent  reaches  the  lung  tissue 
through  the  small  bronchi,  while  in  lobar  pneumonia  it  probably  reaches 
the  lungs  through  the  lymph  or  blood  channels,  causing  primary  inflam- 
mation of  lung  tissue,  which  spreads  rapidly  and  by  extension  includes  the 
fine  bronchi  in  the  inflammation.  This  essential  difference  in  the  patho- 
logical anatomy  of  the  two  diseases  would  indicate  that  lobar  pneumonia 
is  really  a  primary  acute  pneumococcic  infection  which,  as  a  rule,  finds 
more  or  less  extensive  local  expression  in  an  acute  inflammation  and  re- 


456  BROXCHOPNEUMOXIA 

suiting  consolidation  of  lung  tissue,  and  which  involves  and  is  usually  con- 
fined to  either  the  whole  or  part  of  one  lobe;  on  the  other  hand,  broncho- 
pneumonia is  always  secondary  to  bronchitis. 

In  the  so-called  primary  cases  of  bronchopneumonia  the  infectious 
agent,  which  is  commonly  the  pneumococcus,  starts  the  process  by  pro- 
ducing a  sudden  and  violent  bronchitis  of  the  smaller  bronchi,  instead  of 
producing  a  bronchitis  of  the  larger  tubes,  which  more  or  less  gradually 
extends  downward  until  the  finer  bronchi  are  involved.  It  is  a  notable 
fact  that  of  all  the  microorganisms  which  produce  bronchopneumonia, 
pneumococcus  is  practically  the  only  one  that  also  produces  a  lobar  pneu- 
monia, and  it  is  also  worthy  of  note  that  the  younger  the  child  the  greater 
is  the  probability  that  a  pneumococcic  infection  wnll  result  in  broncho- 
pneumonia rather  than  in  lobar  pneumonia. 

While  the  inflammatory  process  in  bronchopneumonia  begins  in  the 
fine  bronchi,  it  does  not  necessarily  extend  by  continuity  of  surface  to  the 
associated  alveoli.  On  the  other  hand,  the  inflammatory  swelling  of  the 
mucous  membrane  commonly  occludes  the  lumen  of  the  small  bronchial 
tubes  to  such  an  extent  that  we  have  atelectasis,  or  collapse  of  the  alveoli. 
In  the  meantime,  the  microorganisms,  exciting  tlie  inflammation,  have 
penetrated  through  the  small  bronchi  and  caused  inflammation  of  the 
peribronchial  tissues  and  adjacent  alveoli,  while  edematous  tissue  surrounds 
the  collapsed  alveoli  above  referred  to.  The  affected  lung,  therefore,  pre- 
sents small  patches  of  atelectasis,  emphysema  and  consolidation.  These 
are  usually  widely  disseminated  throughout  both  lungs  and  are  surrounded 
by  apparently  normal  lung  tissue.  As  the  bronchopneumonic  inflammation 
progresses  the  nodules  increase  in  number  and  in  size,  and  if  they  happen 
to  be  in  close  juxtaposition  they  may  become  confluent,  producing  large 
areas  of  consolidation,  which  are  indistinguishable  by  physical  signs  alone 
from  true  lobar  pneumonia. 

The  nodules  which  hold  in  their  embrace  the  affected  bronchioles, 
peribronchial  tissue  and  alveoli  contain  the  offending  microorganisms,  de- 
generated epithelial  cells,  small  round  cells,  leukocytes,  and  a  mucoid 
and  cellular  exudate  containing  little  fibrin.  Tbe  abundant  fibrinous  exu- 
date which  occurs  in  lobar  pneumonia  is,  as  a  rule,  an  important  differen- 
tiating characteristic  of  the  inflammatory  processes  in  the  two  forms  of 
pneumonia;  yet  it  must  be  admitted  that  bronchopneumonia  may  rarely 
produce  such  an  extensive  and  circumscribed  consolidation  of  the  lung 
that  it  is  difficult  even  for  the  pathologist  to  differentiate  the  two  condi- 
tions. This  confusion  may  arise,  in  some  instances,  from  the  presence  at 
the  same  time  of  bofh  forms  of  pneumonia  in  the  same  or  in  different 
lungs. 

Symptomatology. — General  Symptoms. — The  onset  is,  as  a  rule,  grad- 
ual; there  is  generally  a  preliminary  bronchitis,  which  grows  worse,  until 
a  capillary  bronchitis  and  a  bronchopneumonia  are  produced.  The  transi- 
tion, however,  from  ordinary  bronchitis  to  bronchopneumonia  may  be 
more  sudden ;  in  fact,  may  occur  over  night ;  yet,  on  the  whole,  except  in 


SYMPTOMATOLOGY  457 

the  so-called  primary  form  of  this  disease,  which  will  be  considered  later, 
a  gradual  onset  preceded  by  a  preliminary  bronchitis  markedly  distin- 
guishes this  disease  from  lobar  pneumonia.  Another  distinguishing  char- 
acteristic of  the  onset  of  bronchopneumonia  is  that  the  symptoms  are  de- 
cidedly pulmonary,  pointing  to  a  serious  disease  of  the  lungs,  so  that  the 
physician  is  never  misled,  as  in  lobar  pneumonia,  into  suspecting  that 
the  primary  affection  may  be  in  the  brain    or  in  the  abdomen. 

The  disease  begins  with  a  rise  in  temperature,  a  pronounced  cough  and 
more  or  less  marked  dyspnea.  While  vomiting  is  rare  as  an  initial  S3^mp- 
tom,  later  it  is  quite  common.  With  the  elevation  of  temperature  the  child 
may  complain  of  feeling  chilly,  or,  if  too  young  to  describe  its  symptoms, 
the  chill  may  be  inferred  by  the  cold  extremities  and  the  pinched  expres- 
sion about  the  face.  The  elevation  of  temperature,  which  marks  the 
onset  of  the  disease,  may  reach  102°  or  103  °r.,  and  this  is  followed  by 
remissions,  the  temperature  continuing,  as  a  rule,  to  be  very  irregular 
throughout  the  course  of  the  disease,  being  thus  in  marked  contrast  with 
the  sustained  temperature  of  lobar  pneumonia.  The  cough,  which  was  a 
symptom  of  the  preceding  bronchitis,  becomes  more  irritable  and  harassing, 
and  calls  unmistakable  attention  to  the  lungs  as  the  site  of  the  disease. 
If  the  chest  of  the  child  be  now  uncovered,  inspection  will  reveal  the  most 
characteristic  signs  of  bronchopneumonia.  The  dyspnea,  which  is  such  a 
marked  and  characteristic  symptom,  shows  itself  not  only  by  the  dilata- 
tion of  the  wings  of  the  nose,  but  more  especially  by  the  retraction  of  the 
low^er  portion  of  the  chest,  where  the  diaphragm  is  attached  to  the  chest 
wall.  This  sinking  in  with  each  inspiration  of  the  diaphragmatic  or  peri- 
pneumonic  groove  is  usually  very  noticeable,  even  in  the  very  beginning  of 
the  disease,  and,  as  the  disease  progresses,  this  inspiratory  retraction  of 
the  chest  wall  becomes  a  very  pronounced  and  very  significant  symptom, 
and  with  it  there  is  a  sinking  in  of  the  tissues  in  the  suprasternal  region. 
These  signs,  which  are  produced  by  the  labor  of  the  inspiratory  muscles  in 
their  efforts  to  force  air  into  the  lungs,  indicate  an  air  hunger,  which  is 
caused  by  the  closing  of  great  numbers  of  small  bronchi  and  the  consequent 
cutting  off  of  the  alveoli  from  their  air  supply.  The  younger  the  infant 
the  more  soft  and  flexible  are  the  chest  walls,  and  therefore  the  more 
marked  are  these  physical  signs  of  dyspnea,  which  are  most  characteristic 
and  significant,  both  from  the  standpoint  of  diagnosis  and  prognosis.  As 
the  disease  progresses,  the  infant  becomes  more  and  more  prostrated,  the 
distress  caused  by  the  difficulty  of  breathing  becomes  more  and  more  mani- 
fest, expiration  is  accompanied  by  an  audible  grunt,  the  child's  expression 
becomes  more  anxious,  its  features  drawn,  and  altogether  it  presents  the 
appearance  of  being  critically  ill. 

The  pulse  rate  increases,  varying  from  150  to  200  per  minute;  in  very 
severe  cases  it  may  be  uncountable.  The  rapidity  of  the  pulse,  however,  is 
not  of  so  much  importance  as  its  character;  if  it  be  full  and  strong,  its 
rapidity  causes  little  alarm;  but  if  it  be  weak,  thready,  intermittent,  and 
compressible,  it  is  an  alarming  symptom.     From  the  beginning  the  respira- 


458  BEOXCHOPXEUMOXIA 

tions  are  lal)ored  and  increased  in  frequency;  they  may  vary  from  40  to 
100  per  minute,  and  with  increasing  dyspnea  the  infant  may  be  unable  to 
take  nourishment.  The  prostration  in  these  cases  jiroceeds  apace  with  the 
progress  of  other  severe  symptoms.  Cyanosis  is  a  much  more  marked  and 
prominent  symptom  in  bronchopneumonia  than  it  is  in  lobar  pneumonia. 
It  not  infrequently  occurs  early  in  the  disease.  A  progressive  cyanosis 
with  coldness  and  blueness  of  the  extremities  is  a  very  unfavorable  sign; 
it  indicates  a  weak  circulation  and  insufficient  oxygenation  of  the  blood. 
If  the  disease  gets  progressively  worse,  all  of  the  above  symptoms  become 
aggravated,  the  pulmonary  distress  is  increased,  inspiration  becomes  more 
labored,  and  cyanosis  more  marked,  until  the  whole  body  has  a  slightly 
purplish  appearance.  The  infant  is  no  longer  able  to  take  food ;  it  is  dull, 
listless,  and  lapses  into  unconsciousness.  The  cough,  which  has  been  such 
a  troublesome  symptom,  gradually  groM's  less,  and  finally  disappears,  al- 
lowing the  mucus  to  accumulate  in  the  large  bronchial  tubes.  Large  rales 
appear  in  the  trachea  and  upper  bronchial  tubes,  the  pulse  becomes  more 
feeble  and  flickering,  the  skin,  especially  of  the  extremities,  grows  cold, 
and  death  ensues  from  respiratory  failure,  sometimes  preceded  by  mild 
convulsive  movements. 

If  the  disease  in  bad  cases  terminates  in  recovery,  the  first  favorable 
indication  noted  is  that  the  symptom  group  does  not  grow  worse.  If  the 
dyspnea  remains  at  a  standstill  for  twenty-four  or  thirty-six  hours,  a 
gradual  improvement  may  be  expected  thereafter.  The  character  of  the 
breathing  from  day  to  day  becomes  slightly  less  labored,  and  the  cyanosis 
disappears.  These  two  indications  are  of  the  very  greatest  importance  in 
marking  the  favorable  turning  point  in  bronchopneumonia.  With  this 
improvement  the  temperature  curve  is  lower,  and  the  general  condition  of 
the  patient  slowly  improves.  The  child  takes  food  better,  and  is  again 
interested  in  its  surroundings;  the  harassing  cough  becomes  more  produc- 
tive, as  it  more  satisfactorily  clears  the  bronchial  tubes.  This  disease  runs 
its  course  in  from  three  to  six  weeks,  and  the  temperature  curve  witli  its 
many  irregularities  gradually  becomes  normal.  Bronchopneumonia,  unlike 
lobar  pneumonia,  rarely  terminates  by  crisis. 

In  the  above  outline  of  the  onset  and  general  clinical  history  of  broncho- 
pneumonia no  mention  is  made  of  the  physical  signs  elicited  by  percussion 
and  auscultation.  This  is  not  because  of  their  lack  of  importance  from 
the  standpoint  of  diagnosis,  but  rather  because  they  could  be  better  dis- 
cussed as  individual  symptoms.  It  may,  however,  here  be  noted  that  these 
signs  are  of  much  less  value  in  the  diagnosis  of  bronchopneumonia  than  in 
lobar  pneumonia.  The  coarse  rales  of  a  more  or  less  general  bronchitis, 
with  perhaps  small  scattered  areas  of  fine  crepitation,  may  be  heard  in 
nearly  every  case  of  bronchopneumonia,  but,  after  all,  the  diagnosis  does 
not  depend  upon  these  findings  so  much  as  it  does  upon  the  general  clinical 
picture  above  given. 

Individual  Symptoms. — The  fever  of  ordinary  bronchopneumonia  is, 
as  the  accompanying  charts  show,  very  irregular.     It  is  characterized  by 


SYMPTOMATOLOGY 


459 


marked  remissions  and  sometimes  intermissions,  even  when  the  tempera- 
ture is  running  as  high  as  104°  or  10o°F.  The  remissions  or  intermissions 
usually  occur  in  the  morning,  and  the  sharp  exacerbations  in  the  after- 
noon. At  times  the  temperature  may  remain  near  the  normal  line  for  a 
number  of  days  in  succession,  and  then  rise  and  again  proceed  on  its  ir- 
regular course. 

On  the  whole,  the  temperature  of  bronchopneumonia  is  of  little  value 
from  the  standpoint  of  prognosis.  A  low  or  even  a  normal  temperature 
may  be  present  in  fatal  cases ;  this  is  especially  true  in  young,  malnourished 
infants.  The  temperature  curve,  therefore,  of  bronchopneumonia  must 
be  studied  in  connection  with  other  symptoms.     A  fall  of  temperature, 


DAV 
OF  MONTH 

IS 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

DAy 
OF  DISEASE 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

II 

12 

107° 
106° 

105° 

bJ 

§      104 

£      103° 

Q. 

E 

"      102° 

t 

bJ              o 

z      101 

z 

UI 

1    "">' 

u. 

99° 

98° 

97° 

/\ 

\ 

X 

/^ 

\/ 

' 

^ 

1 

/^ 

V 

r\ 

V 

J 

f 

\ 

A 

i 

t 

^y 

V 

\ 

\/ 

/ 

V 

A 

{ 

\ 

1 

V 

\ 

L 

A 

V 

S. 

PULSE 

's 

s 

i 

g 

° 

o 

" 

s 

S 

1 

S 

I 

1 

2 

K 

g 

§ 

s 

s 

2 

2 

g 

g 

? 

HESPfRATION 

s 

z 

? 

z 

5 

s 

s 

; 

£. 

s 

s 

s 

S 

s 

S 

£ 

? 

s 

5 

£■ 

S 

£ 

S 

s 

Fig.  73. — Mild  Bronchopneumonia. 


when  coincident  with  an  improvement  in  other  symptoms,  is  a  good  in- 
dication, but  a  fall  or  a  slow  decline,  when  associated  with  no  improve- 
ment, or  an  increase  in  the  dyspnea  and  other  severe  symptoms,  is  a  bad 
indication.  A  prolonged  and  decidedly  intermittent  temperature,  lasting 
for  some  time,  may  suggest  some  complication,  such  as  tuberculosis,  em- 
pyema, or  septic  infection  of  the  ear.  In  primary  bronchopneumonia  the 
temperature  curve  is  similar  to  that  of  lobar  pneumonia ;  it  rises  suddenly, 
remains  high  for  from  five  to  seven  days,  and  then  drops  to  normal,  usu- 
ally terminating  by  crisis. 

The  Urine. — The  urine,  in  a  large  percentage  of  the  severe  cases,  con- 
tains a  small  amount  of  albumin  with  perhaps  a  few  hyalin  and  an  occa- 
sional granular  cast.     This  condition  of  so-called  acute  degeneration  of 


460 


BROXCHOPNEUMOXIA 


the  kidney,  which  may  occur  in  all  febrile  and  toxic  conditions,  is  of  com- 
paratively little  importance.  The  urine  clears  up  when  the  bronchopneu- 
monia disappears,  and  very  rarely,  indeed,  does  acute  Bright's  disease 
develop. 

Sputum. — The  sputum,  from  the  standpoint  of  diagnosis,  is  of  com- 
paratively little  importance,  because  it  is  so  difficult  to  obtain.  In  infants 
it  is  rarely,  if  ever,  justifiable  to  attempt  to  obtain  the  sputum  by  insert- 
ing a  gauze-wrapped  finger  into  the  pharynx.  In  older  children,  in  whom 
tuberculous  bronchopneumonia  is  suspected,  this  process  may  be  successfully 


OAV 

OF  MONTH 

8 

9 

10 

M 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

OAV 

OF  DISEASE 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

II 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

107' 

106° 

105° 

S    104° 

3 

£    '03' 

a 

u    102° 

5    101' 

X 

S  100° 

98° 
97° 

^ 

A 

\ 

\ 

f 

V 

h 

V 

\ 

f 

\ 

s, 

1 

h 

/ 

y 

r 

J 

N 

\ 

\ 

^ 

u 

f 

V 

^ 

A 

l\ 

'1 

f\ 

i 

\l 

< 

/ 

/ 

1, 

y 

V 

^ 

\> 

/ 

i 

1 

f ' 

V 

V 

V 

V 

1 

\ 

{ 

J 

1 

/ 

PUISE 

- 

S 

? 

s 

3 

1 

S 

£ 

I 

% 

5 

% 

£ 

s 

S 

% 

S 

E 

1 

I 

£; 

^ 

s 

£ 

» 

£ 

s 

e 

o 

i 

s 

s 

? 

s 

s 

? 

S 

•• 

o 

s 

? 

<c 

RESPIRATION 

I 

s 

•" 

s 

S 

O 

S 

S 

S 

% 

a. 

% 

i 

5 

• 

£ 

: 

S 

s 

s 

1 

iJ 

s 

5 

s 

i 

£j 

s 

? 

R 

iJ 

s 

i 

s 

s 

c 

s 

s 

s 

: 

« 

s 

Fig.  74. — Severe  Bronchopneumonia. 


used,  and  the  finding  of  tubercle  bacilli  in  the  sputum  changes  both  the 
diagnosis  and  prognosis. 

Physical  Signs. — In  the  beginning,  when  small  areas  of  consolidation 
are  scattered  widely  throughout  the  lungs,  percussion  is  of  little  value,  as 
the  note  thus  elicited  is  either  normal  or  slightly  emphysematous.  Later 
in  the  disease,  when  these  small  islands  of  consolidation  have  coalesced, 
dullness  maj*  be  elicited  on  light  percussion ;  this  is  the  more  readily  found 
posteriorly  in  the  lower  portion  of  the  lung.  At  times  large  areas  of  con- 
solidation may  occur,  giving  rise  to  physical  signs  very  similar  to  those  of 
lobar  pneumonia.  Auscultation  is  of  great  value  in  confirming  the  diag- 
nosis of  bronchopneumonia,  since  in  well-developed  cases  one  can  usually 
discover  fine  moist  rales  over  small  areas  widely  distributed,  especially  in 
the  region  of  the  spine  and  base  of  the  lungs,  and  they  may  also  be  found 
anteriorly  and  laterally.     Coarser  moist  rales  may  also  be  heard  rather 


TYPES    OF    BRONCHOPNEUMONIA  461 

widely  distributed.  The  fine  erepitant  and  subcrepitaut  rales  found  in 
bronchopneumonia  differ  from  those  of  lobar  pneumonia,  in  that  they  are 
more  widely  distributed,  occurring  in  small  areas  over  both  lungs;  they 
are  also  more  evanescent,  disappearing  at  one  point  and  reappearing  at 
another.  As  larger  portions  of  the  lung  become  consolidated,  they  may  be 
found  over  larger  areas  and  may  be  associated  with  bronchophony  and 
bronchial  breathing.  The  crying  and  coughing  of  the  child  often  develop 
or  make  more  pronounced  the  physical  signs.  The  pulmonary  inflamma- 
tion is  more  marked  in  the  lower  portions  of  the  lungs,  and  comes  to  the 
surface  more  readily  posteriorly  than  it  does  anteriorly,  because  of  the 
dorsal  position  of  the  child  during  its  illness;  as  it  lies  so  continuously 
upon  its  back  the  lower  and  posterior  portions  of  the  lungs  are  not  properly 
drained. 

Types  of  Bronchopneumonia. — Many  variations  from  the  ordinary  type 
are  seen.  The  most  important  of  these  is  primary  or  pneumococcic  broncho- 
pneumonia. The  onset  and  temperature  curve  of  this  condition  is  very 
similar  to  that  of  lobar  pneumonia ;  it  runs  a  definite  course,  terminates  by 
crisis  in  from  five  to  nine  days,  and  is  followed  by  a  rapid  convalescence. 
The  general  clinical  picture  of  this  condition  has  already  been  described 
in  the  chapter  on  Lobar  Pneumonia. 

An  abortive  type  of  pneumonia  is  recognized  by  all  clinicians.  Cases 
of  bronchopneumonia  as  well  as  of  lobar  pneumonia  are  seen,  which  begin 
with  the  typical  onset  and  show  the  characteristic  symptoms  and  physical 
signs  of  these  diseases,  in  which  suddenly,  on  the  third  or  fourth  day,  the 
temperature  falls  to  normal,  the  general  symptoms  as  well  as  the  physical 
signs  disappear,  and  a  rapid  convalescence  follows.  These  cases  are  de- 
scribed by  some  authors  under  the  term  "Acute  Pulmonary  Congestion," 
but  there  is  ample  clinical  and  pathological  proof  that  many  of  these  cases 
are  pneumonia. 

Prolonged  bronchopneumonia  with  migrating  areas  of  consolidation  is 
commonly  produced  by  the  influenza  bacillus. 

Bronchopneumonia  of  the  New-born. — During  the  first  weeks  of 
life  bronchopneumonia  is  a  very  insidious  disease,  and  usually  occurs  as 
the  sequel  of  epidemic  grippe  or  influenza.  The  earliest  symptoms  are 
cold  in  the  head,  nasal  catarrh,  slight  cough,  and  pharyngeal  irritation, 
followed  perhaps  by  laryngitis,  bronchitis,  and  finally  bronchopneumonia. 
The  progress  of  the  disease,  however,  in  the  infant  is  so  masked  that  it  is 
likely  to  be  overlooked.  There  is  but  slight  elevation  of  temperature  as- 
sociated wdth  an  increasing  cough  and  slight  dyspnea,  and  as  the  infant 
of  this  age  has  so  little  resistance,  a  well-marked  and  incurable  broncho- 
pneumonia not  uncommonly  develops  before  serious  disease  of  the  lung  is 
suspected.  At  this  age  the  disease  is  nearly  always  associated  with  gastro- 
intestinal disturbances,  which  hasten  its  unfavorable  termination.  Al- 
though this  condition  is  comparatively  rare  and  is  most  commonly  seen 
in  weaklings,  yet  the  fact  that  it  may  develop  so  insidiously  should  make 
the  physician  most  careful  to  give  prompt  attention  to  all  catarrhal  diseases 


463  BRONCHOPNEUMOXTA 

of  the  upper  air  passages  in  young  infants.  Little  can  be  done  to  save 
them  after  the  bronchopneumonia  has  developed,  but  much  can  be  done  to 
safeguard  them  against  this  disease  if  the  early  catarrhal  conditions  are 
properly  looked  after. 

Deglutition  Pneumonia. — Following  intubation,  and  paralysis  of  the 
soft  palate,  food  particles  infected  in  the  diphtheritic  throat  may  be  as- 
pirated into  the  lung  and  cause  pneumonia.  It  is  not  the  foreign  body 
but  the  infection  it  carries  with  it  that  causes  the  localized  inflammation 
of  the  lung.  In  whooping-cough  the  deep  inspiration  which  follows  the 
paroxysm  of  cough  may  suck  particles  of  food  far  into  the  branches  of  the 
bronchial  tree.  If  these  foreign  particles  are  infected  and  become  lodged, 
they  may  excite  a  localized  bronchopneumonia,  terminating  in  abscess. 
Noninfected  food  particles  or  other  clean  foreign  bodies  may  cause  bron- 
chial irritation,  but  not  bronchopneumonia. 

Bronchopneumonia  Following  Gastroenteritis. — One  of  the  dan- 
gers of  chronic  and  subacute  enteritis  is  a  complicating  bronchopneumonia. 
In  many  of  these  cases  it  is  a  terminal  infection,  occurring  but  a  short 
time  before  the  fatal  issue.  Terminal  bronchopneumonia  may  also  occur 
in  other  wasting  diseases. 

Tuberculous  Bronchopneumonia. — This  is  one  of  the  common  forms. 
In  the  beginning  it  presents  the  picture  of  an  ordinary  bronchopneumonia, 
but  fails  to  clear  up  in  three  or  four  weeks,  although  the  temperature  and 
acute  symptoms  may  have  somewhat  subsided.  It  occurs  most  frequently 
in  infancy,  but  may  occur  in  older  children.  The  cough  is  tenacious,  the 
dyspnea  is  marked,  although  not  excessive,  the  fever  is  remittent,  some- 
times intermittent,  falling  in  the  morning  and  rising  to  104°  or  105 °F.  in 
the  afternoon.  The  sharp  exacerbation  in  temperature  which  occurs  at 
least  once  in  twenty-four  hours  does  not  always  come  at  the  same  time  of 
the  day.  There  is  progressive  emaciation  and  loss  of  strength,  and  the 
disease  may  continue  for  five  or  six  weeks.  As  it  progresses,  large  areas 
of  consolidation  appear;  the  whole  of  both  lobes  posteriorly  may  be  con- 
solidated, or  the  consolidation  may  be  in  other  parts  of  the  lung.  Over 
these  consolidated  areas  there  is  marked  dullness,  tubular  breathing  and 
bronchophony,  and  large  and  fine  rales  may  be  heard.  The  physical  signs 
are,  in  fact,  almost  identical  with  those  of  lobar  pneumonia.  The  diag- 
nosis may  sometimes  be  made  by  examining  the  sputum.  As  a  rule,  there 
is  a  family  history  of  tuberculosis,  with  perhaps  a  previous  personal  his- 
tory of  glandular  tuberculosis.  The  areas  of  consolidation  are  persistent 
and  do  not  shift,  as  in  other  forms  of  prolonged  bronchopneumonia. 

Complications. — Pleurisy  is  as  important,  although  not  so  common,  a 
complication  of  bronchopneumonia  as  it  is  of  lobar  pneumonia.  When  it 
does  supervene,  however,  it  is  usually  purulent  in  character.  An.  empyema 
complicating  a  bronchopneumonia  may  prolong  the  fever  and  cause  the 
temperature  curve  to  assume  a  septic  type,  falling  to  normal  or  below 
normal  in  the  morning  and  rising  rapidly  to  104°  or  105°F.  in  the  after- 
noon; it  does  not  always  reach  its  highest  or  its  lowest  point  at  the  same 


DIAGNOSIS  463 

hours  every  day,  and  tliere  may  be  more  than  one  such  exacerbation  dur- 
ing the  twenty-four  hours.  This  irregular,  sharply  remittent  or  intermit- 
tent fever,  following  a  bronchopneumonia,  usually  indicates  either  em- 
pyema, otitis  media,  or  a  complicating  tuberculosis.  The  differential  diag- 
nosis between  these  conditions  must  be  made  by  the  associated  symptoms. 
Otitis  media  is  a  frequent  complication.  It  may  produce  the  septic  tem- 
perature curve  above  described,  and  under  these  conditions,  if  empyema 
and  tuberculosis  can  be  excluded,  the  existence  of  an  otitis  media  becomes 
more  probable.  Moreover,  it  is  usually  associated  with  pain,  so  that  the 
increased  restlessness,  sleeplessness  and  irritability  of  the  child  may  sug- 
gest to  the  physician  the  possibility  of  earache,  and  an  examination  of 
the  ear  drum  may  confirm  the  diagnosis.  J^ot  infrequently,  however, 
this  complication  is  overlooked  until  the  mother  or  nurse  announces  that 
the  patient  has  a  purulent  discharge  from  the  ear.  Pericarditis  is  a  rare 
complication.  When  it  does  occur,  however,  it  is  nearly  always  purulent 
and  leads  to  a  fatal  issue.  A  weak  and  dilated  heart  muscle  may  be  an 
unfavorable  complication  in  cases  of  bronchopneumonia,  associated  with 
severe  attacks  of  whooping-cough.  Meningitis,  arthritis  and  osteomyelitis 
are  possible  complications. 

Diagnosis. — In  lobar  pneumonia,  as  previously  noted,  it  is  often  a  ques- 
tion of  the  organ  involved,  as  the  symptom  group  in  this  disease  may  be 
so  misleading  that  the  physician's  attention  is  not  called  to  the  lung  as 
the  site  of  the  disease.  This  very  rarely  occurs  in  bronchopneumonia.  In 
this  disease  the  pulmonary  symptoms  are  so  prominent  that  attention  is 
at  once  directed  to  the  lungs.  The  only  question,  therefore,  which  is  likely 
to  arise  is  as  to  the  character  of  the  pneumonia.  Is  it  a  lobar,  or  a 
bronchopneumonia?  If  the  latter,  what  is  the  character  of  the  broncho- 
pneumonia ?  As  the  differential  diagnosis  of  the  different,  forms  of  bron- 
chopneumonia have  already  been  considered,  it  only  remains  here  to  note 
the  points  of  difference  between  lobar  and  bronchopneumonia.  When  the 
characteristic  physical  signs  of  these  diseases  are  well  defined  there  is  little 
difficulty.  In  lobar  pneumonia  we  may  have  large  areas  of  consolidation 
confined  to  one  lobe,  with  marked  dullness,  bronchial  breathing,  and  sub- 
crepitant  rales  scattered  over  this  consolidated  area,  the  other  portions  of 
the  lungs  being  comparatively  free  from  physical  signs.  In  bronchopneu- 
monia the  dullness  may  be  absent,  but  fine  crepitant  and  subcrepitant  rales 
may  be  found  from  time  to  time  in  small  areas  scattered  rather  widely 
over  both  lungs,  and  with  this  we  have  coarser  rales  in  the  larger  bronchi. 
Unfortunately,  however,  these  clearly  defined  physical  signs  are  not  always 
present,  or  they  may  be  so  commingled  in  an  individual  case  that  the  physi- 
cian is  left  in  doubt  as  to  the  character  of  the  pneumonia.  For  these  rea- 
sons the  clinical  history  of  the  two  pneumonias  is  of  quite  as  much  im- 
portance as  the  physical  signs  in  making  a  diagnosis.  Bronchopneumonia 
differs  from  croupous  pneumonia  in  that  it  is  usually  a  secondary  disease, 
having  a  more  gradual  onset.  Its  temperature  curve  is  not  at  all  char- 
acteristic, being  irregular  in  character  and  running  no  definite  course,  and, 
31 


4G4  BRONCHOPNEUMOXIA 

most  important  of  all,  dysjjuea  and  possibly  cyanosis  may  be  marked  and 
early  symptoms.  The  early  and  more  or  less  characteristic  dyspnea,  which 
has  above  been  carefully  dwelt  upon,  is  of  great  value  in  differential  diag- 
nosis. 

Prognosis. — This  is  one  of  the  most  serious  and  dangerous  diseases  of 
early  life.  Even  under  the  most  favorable  conditions  the  death  rate  is  25 
per  cent.  In  hospitals  and  other  institutions,  where  children  are  crowded 
together,  the  mortality  may  reach  from  40  to  60  per  cent.  Age  is  an 
important  factor  in  determining  the  death  rate.  In  the  new-born  the  dis- 
ease is  almost  always  fatal;  during  the  first  year  of  life  it  reaches  30  to 
40  per  cent. ;  during  the  second  year  of  life  it  falls  below  25  per  cent.,  and 
thereafter  continues  to  diminish,  until  between  the  third  and  fifth  year  of 
life  the  mortality,  under  favorable  conditions,  generally  does  not  exceed 
10  per  cent.  The  physical  condition  of  the  child  greatly  influences  the 
death  rate.  The  mortality  is  very  high  in  syphilitic,  rachitic,  tuberculous, 
and  other  malnourished  infants,  and  when  associated  with  enteritis  is  al- 
most always  fatal.  The  mortality  is  much  greater  in  bottle-fed  than  in 
breast-fed  infants.  The  death  rate  is  higher  in  the  middle  and  northern 
States  during  the  cold  and  changeable  winter  months,  because  this  climate 
and  this  season  are  not  so  favorable  to  the  fresh-air  treatment  of  this  dis- 
ease. The  mortality  is  also  influenced  by  the  character  of  the  infection 
which  produces  the  bronchopneumonia.  In  tuberculous  cases  it  is  bad.  In 
pneumococcic  or  primary  bronchopneumonia  the  prognosis  is  good;  nearly 
all  of  these  cases  get  well,  except  those  which  occur  in  weak  and  delicate 
infants  during  the  first  year  of  life.  The  mortality  is  higher  in  tlie  cases 
following  diphtheria,  scarlet  fever  and  whooping-cough  than  it  is  in  those 
produced  by  measles,  influenza  or  simple  bronchitis. 

Prophylaxis. — Fresh  air  and  good  hygiene  are  the  keynotes  in  the 
prophylactic  treatment  of  this  disease.  Bronchopneumonia,  in  the  vast 
majority  of  cases,  is  secondary  to  bronchitis,  and  there  is  little  doubt  that 
if  children  suffering  from  the  various  acute  infectious  diseases  and  from 
ordinary  simple  bronchitis  could  be  isolated  from  other  children,  and  could 
have  fresh,  pure  air,  uncontaminated  by  bacteria,  bronchopneumonia  would 
be  a  comparatively  rare  disease.  Many  of  the  cases  of  bronchitis  occurring 
in  institutions,  and  in  tenement  houses,  are  forced  to  breathe  impure 
air,  which  carries  secondary  infections  of  various  kinds  to  their  bronchial 
mucous  membranes,  and  bronchopneumonia  results.  The  necessity,  there- 
fore, of  looking  upon  every  case  of  bronchitis  in  infancy  with  reference  to 
the  possible  development  of  bronchopneumonia  is  of  the  greatest  impor- 
tance. Every  case  should  be  isolated,  protected  from  all  possible  conta- 
gion, and,  above  all,  should  have  plenty  of  fresh  air.  The  younger  the 
child  the  more  important  are  these  precautions.  In  infants,  during  the 
first  few  weeks  of  life,  every  simple  coryza  and  pharyngeal  irritation  should 
receive  prompt  and  careful  attention,  since  at  this  age  the  prophylactic 
treatment  of  bronchopneumonia  is  the  only  treatment  that  is  of  any  avail. 

Treatment. — The  first  and  most  important  thing  in  the  treatment  of 


TREATMENT  465 

bronchopneumonia  is  to  place  the  patient  under  proper  hygienic  surround- 
ings. A  large,  well-ventilated  and  isolated  room  is  to  be  selected,  in  which 
the  patient  is  to  remain  under  the  care  of  a  competent  nurse.  All  unnec- 
essary callers  are  to  be  excluded,  in  order  that  quiet  may  reign,  and  that 
the  air  may  be  as  little  contaminated  as  possible. 

Hygienic  Treatment. — Fresh  air  is  the  most  important  curative  agent 
in  bronchopneumonia,  even  more  important  here  than  in  lobar  pneumo- 
nia. At  all  seasons  of  the  year  the  windows  of  the  room  must  be  open, 
to  give  an  abundant  inflow  of  fresh,  cool  air.  The  importance  of  the 
fresh-air  treatment  of  this  disease  cannot  be  exaggerated,  and  the  laity 
must  be  given  to  understand  that  without  it  all  other  methods  of  treatment 
are  comparatively  useless.  For  many  years  Xorthrup  has  taught  and  has 
insisted  that  the  fresh-air  treatment  would  greatly  reduce  the  mortality 
of  this  disease,  and  he  has  done  much,  as  have  thousands  of  other  physi- 
cians, to  bring  the  laity  to  understand  that  there  is  little  or  no  danger  of 
"catching  cold"  by  the  fresh-air  or  outdoor  treatment  of  bronchopneumonia, 
provided  it  is  properly  carried  out.  What  the  laity  calls  "catching  cold" 
results  from  exposing  these  patients  indoors  to  an  air  tliat  is  contaminated 
with  pathogenic  microorganisms.  Fresh,  pure,  cold  air  must,  therefore,  be 
had  wherever  the  patient  is  located.  The  outdoor  air  of  any  locality  is 
infinitely  better  than  the  indoor  air;  so  that  if  these  cases  must  be  treated 
in  the  downtown,  smoky  atmosphere  of  our  closely  crowded  tenement 
houses,. the  windows  should  be  opened  and  this  air  let  in  in  abundance,  to 
replace  the  contaminated  air  of  the  sick  room.  During  winter  the  body 
of  the  child  must  be  kept  warm  with  proper  clothing,  and  possibly  arti- 
ficial heat.  At  this  season  the  infant  should  always  be  carefully  hooded 
with  some  warm  material,  and  the  temperature  of  the  room  in  the  neigh- 
borhood of  the  child's  bed  should  not  be  allowed  to  fall  below  60°  or 
65 °F.  This  can  be  accomplished  by  artificial  heat,  even  though  the  end 
and  side  windows  of  the  room  be  open.  The  bed  of  the  infant  is  not  to 
be  placed  between  the  windows. 

Dietetic  Treatment. — From  what  has  been  said  of  the  seriousness 
of  gastrointestinal  complications,  one  realizes  the  importance  of  the  dietetic 
treatment.  If  the  child  be  a  nursing  infant,  breast  feeding  must  be  per- 
severed in;  and  as  the  child  becomes  too  ill  to  take  the  breast,  as  it  almost 
always  does  within  a  few  days,  every  effort  must  be  made  with  breast 
pumps  and  other  devices  to  keep  the  mother's  milk  from  drying  up,  and 
to  secure  in  this  artificial  way  a  certain  amount  of  breast  milk,  which 
can  be  fed  to  the  infant  with  a  spoon.  In  artificially  fed  babies  the  food 
selected  must  depend  upon  the  age  and  digestive  capacity  of  the  individual 
infant,  the  physician  remembering  that  wliatever  may  have  been  the 
digestive  capacity  of  the  baby  during  health,  it  is  perhaps  diminished  one- 
half  by  an  attack  of  bronchopneumonia.  In  young  infants,  therefore,  the 
milk  formula  given  in  health  should  be  reduced  not  only  in  strength,  but 
in  quantity.  Predigested  foods,  skimmed  milk,  meat  juice,  and  albumin 
water  may  be  necessary  in  the  feeding  of  young  and  delicate  infants.     The 


106  BROXCHOPXEUMONIA 

importance  of  this  subject  is  so  great  that  the  clinician  should  understand 
that,  especially  in  early  infancy,  it  is  just  as  important  not  to  overfeed  as 
it  is  to  give  foods  which  are  within  the  digestive  capacity  of  the  individual 
infant. 

Whiskey  or  brandy  should  be  given  in  all  cases  of  bronchopneumonia. 
Of  the  two,  good  old  rye  whiskey  is  perhaps  the  better.  It  may  be  given 
well  diluted  with  water,  and  sweetened  if  necessary.  Most  children  can 
be  induced  to  take  it  in  this  form  without  resistance.  In  a  long-continued 
disease,  such  as  bronchopneumonia,  where  the  child  is  necessarily  underfed, 
whiskey  serves  as  a  food;  it  keeps  up  the  strength  and  prevents  excessive 
waste  of  tissues.  An  infant  one  year  of  age  may  take  20  or  30  drops 
every  four  hours ;  a  child  two  or  three  years  of  age,  a  teaspoonf ul.  Larger 
or  stimulating  doses  of  whiskey  or  brandy  may  be  given  in  bad  cases, 
especially  when  the  amount  of  food  taken  is  small.  I  have  for  many  years 
used  whiskey  as  a  routine  measure  in  all  severe  cases  of  bronchopneumonia, 
and  have  found  that  it  rarely,  if  ever,  produces  gastrointestinal  disturbance. 

Medical  Treatment. — In  beginning  the  treatment  the  bowels  should 
be  opened  with  castor  oil,  and  this  should  be  repeated  every  third  or  fourth 
day  throughout  the  disease.  This  serves  the  purpose  of  carrying  off  the 
mucus  which  the  child  has  coughed  up  and  swallowed,  and  perhaps  thereby 
prevents  intestinal  infection. 

Tincture  of  strophanthus  or  tincture  of  digitalis  (the  former  is  pre- 
ferable) should  be  given  every  four  hours  throughout  the  course  of  the 
disease.  One  drop  of  tincture  of  strophanthus  is  a  suitable  dose  for  a 
child  one  year  of  age,  and  two  drops  for  a  child  three  years  of  age.  Caf- 
fein-sodium-benzoate,  or  salicylate,  in  one-grain  doses  by  the  mouth,  or 
one-half-grain  doses  hypodermically,  is  a  valuable  circulatory  stimulant, 
which  may  be  given  if  the  pulse  becomes  feeble  and  intermittent. 

Strychnin  is  another  drug  very  widely  recommended,  and  is  of  value 
both  as  a  general  tonic  and  as  a  respiratory  stimulant.  It  may  be  given 
combined  with  whiskey,  1/300  of  a  grain  every  three  or  four  hours,  to 
an  infant  one  year  of  age,  and  1/200  of  a  grain  to  an  infant  two  years 
of  age.  The  chief  objection  to  the  use  of  strychnin  is  that  its  bitterness 
makes  the  whiskey  unpalatable,  and  for  this  reason  it  often  becomes  neces- 
sary to  force  the  infant  to  take  this  combination.  It  is  a  wise  policy,  and 
one  that  should  be  followed  within  limits,  to  cater  to  the  tastes  of  infants 
both  in  food  and  medicines  when  they  are  seriously  ill  with  any  disease. 
It  may,  therefore,  be  unwise  to  attempt  to  mix  with  the  whiskey  unpalatable 
medicines  which  will  cause  the  infant  to  struggle  against  their  administra- 
tion. Forcing  either  foods  or  medicines  into  the  stomach  of  a  child  very 
ill  with  bronchopneumonia  not  only  exhausts  the  strength,  but  often 
causes  vomiting.  The  use  of  strychnin,  therefore,  is  perhaps  better  re- 
stricted to  the  later  stages  of  the  disease,  when  a  respiratory  stimulant  is 
urgently  needed  and  should  then  be  given  hypodermically.  Oxygen  is  a 
good  respiratory  stimulant,  and  before  the  days  of  the  fresh-air  treatment 
was  one  of  the  most  valuable  remedies.    It  still,  however,  has  a  place  in  the 


TREATMENT  467 

treatment  of  this  disease,  even  when  the  child  is  getting  all  the  fresh  air 
it  can  possibly  have.  It  is  especially  indicated  in  the  later  stages  when  the 
inspiratory  dyspnea  is  very  marked  and  cyanosis  is  present.  It  is  easily 
administered  by  inhalation  without  disturbing  the  child ;  the  funnel  which 
is  connected  M'ith  a  tank  of  oxygen  by  rubber  tubing  is  suspended  just  above 
its  mouth  and  nose. 

Sedatives  must  be  used  with  great  care  in  bronchopneumonia,  and  they 
are  of  much  less  value  here  than  in  lobar  pneumonia.  The  temptation 
is  very  great  to  try  to  influence  with  sedatives  the  irritable  and  harassing 
cough  of  bronchopneumonia.  But  it  should  be  remembered  that  the  young- 
er the  child  the  more  dangerous  is  all  sedative  medication.  Opiates  are 
rarely  indicated  under  two  years  of  age.  Now  and  then,  perhaps,  a  sturdy 
infant  with  a  severe  and  harassing  cough  may  be  slightly  benefited  by  a 
few  drops  of  paregoric  or  a  small  dose  of  codein.  But  within  the  last  ten 
years  I  have  not  in  a  single  case  thought  it  advisable  to  give  opium  in 
any  form  to  a  patient  under  two  years  of  age.  Opium  produces  constipa- 
tion, destroys  the  appetite,  disturbs  the  digestion  and  does  much  more  harm 
than  good.  I  believe  that  the  injudicious  use  of  opium  as  a  cough  seda- 
tive has  in  the  past  been  responsible  for  no  small  percentage  of  the  deaths 
produced  by  bronchopneumonia.  Opium,  therefore,  should,  with  the  ex- 
pectorants and  medical  antipyretics,  be  classed  among  the  dangerous  rather 
than  the  beneficent  remedies  in  bronchopneumonia.  Bromid  of  potash 
in  four-  to  five-grain  doses,  with  tincture  of  belladonna  in  one-minim  doses, 
may,  when  combined  in  some  palatable  vehicle,  serve  a  useful  purpose  as  a 
cough  sedative  in  certain  cases,  but  even  these  drugs  find  their  greatest  indi- 
cation in  children  over  two  years  of  age.  Under  this  age  they  should  be 
used  only  when  absolutely  necessary  and  should  be  discontinued  if  they 
produce  the  slightest  gastric  or  intestinal  disturbance. 

Expectorants  should  have  no  place  in  the  treatment  of  bronchopneu- 
monia in  children  under  two  years  of  age.  Tartar  emetic,  syrup  of 
ipecac,  syrup  of  squill,  carbonate  and  muriate  of  ammonia,  in  my  opin- 
ion, do  more  harm  than  good.  The  widespread  use  of  these  drugs  is,  I 
believe,  responsible  for  no  small  part  of  the  mortality  of  this  disease  in 
early  infancy.  They  may  dislodge  a  certain  amount  of  mucus  in  the 
throat  and  upper  air  passages,  but  the  temporary  improvement  in  the 
breathing,  produced  in  this  way,  is  more  than  counterbalanced  by  the  harm 
they  do  in  destroying  the  appetite,  disturbing  the  digestion,  and  cutting 
off  the  nutrition  of  the  child.  In  a  long  and  prostrating  disease,  such  as 
bronchopneumonia,  any  medicine  that  interferes  with  nutrition  or  disturbs 
the  appetite  or  digestion  will  do  more  harm  than  good.  In  older  children 
the  careful  use  of  these  expectorants  may  perhaps  be  of  value. 

Antipvretics  are  of  much  less  value  and  are  much  less  frequently  called 
for  in  bronchopneumonia  than  in  lobar  pneumonia.  The  fever  of  broncho- 
pneumonia is  remittent  or  intermittent  in  type,  and  little  or  nothing  is 
to  be  gained  by  drugs  or  other  agents  used  for  lowering  the  temperature. 
Phenacetin,  antipyrin,  and  other  drugs  of  this  class,  which  may  occasionally 


468  BRONCHOPNEUMONIA 

be  used  to  advantage  in  older  children  suflEering  from  lobar  pneumonia,  do 
much  more  harm  than  good  in  bronchopneumonia.  Cold  packs,  which  are 
of  value  in  many  cases  of  lobar  pneumonia,  are  not  so  generally  used  in 
bronchopneumonia,  and  they  are,  in  my  opinion,  decidedly  contraindicated 
in  infants  sujffering  from  marked  inspiratory  dyspnea  or  cyanosis.  A 
warm  bath  twice  a  day,  or  a  tepid  sponge  bath  three  or  four  times  in 
twenty-four  hours,  is  of  value.  These  baths  act  as  a  sedative  to  the  nervous 
system,  promote  elimination  through  the  skin,  and  serve  as  a  general  tonic 
to  nutritional  processes.  They  are  not  given  with  the  idea  of  lowering 
the  temperature.  Priessnitz  applications  are  of  value  in  both  forms  of 
pneumonia ;  a  light,  sleeveless  flannel  jacket  made  to  fit  the  child  is  dipped 
in  and  wrung  out  of  water  at  a  temperature  of  70°F. ;  this  is  snugly  ap- 
plied to  the  entire  chest  and  covered  with  a  similar  dry  flannel  jacket.  The 
wet  jacket  may  be  removed  and  reapplied  at  intervals  of  from  i/>  hour  to 
3  hours,  as  the  exigencies  of  the  individual  case  demand. 

Counter-irritants  and  Poultices. — Nearly  all  writers,  at  the  present 
time,  recommend  counter-irritants  and  condemn  poultices.  Notwithstand- 
ing this  almost  universally  expressed  opinion,  I  believe  that  the  present- 
day  teachings  are  too  liberal  in  their  recommendation  of  counter-irritants, 
and  too  sweeping  in  their  condemnation  of  poultices.  Counter-irritation  is 
of  much  less  value  in  bronchopneumonia  than  it  is  in  lobar  pneumonia. 
If  a  counter-irritant  is  applied  to  the  chest  of  an  infant  suffering  from 
bronchopneumonia,  it  must,  to  do  any  good,  cover  the  skin  of  the  entire 
chest,  or  be  applied  with  special  severity  to  the  skin  covering  its  posterior 
surface.  Counter-irritations  with  mustard  plasters  and  mustard  baths  fre- 
quently do  more  harm  than  good;  to  be  of  any  value  they  must  redden 
the  skin  and  produce  more  or  less  discomfort  and  irritation,  and  this  in- 
creases the  child's  restlessness,  nervousness  and  sleeplessness,  without  per- 
haps producing  any  favorable  influence  on  the  general  and  widespread  in- 
flammation of  the  lungs,  which  is  seated  some  distance  beneath  the  skin. 
If  counter-irritation  of  any  kind  is  used,  I  much  prefer  warm  camphorated 
oil  of  double  strength.  When  this  is  rubbed  into  the  chest  of  the  child  it 
produces  a  mild  counter-irritation,  and  the  camphor,  some  of  which  is  per- 
haps absorbed,  acts  as  a  general  stimulant.  On  the  other  hand,  poultices 
and  the  oil-silk  jacket  so  universally  condemned  are  of  great  value  in  the 
early  stages  of  bronchopneumonia  when  the  disease  is  spreading,  or  when 
it  is  passing  over  from  a  general  bronchitis  into  a  capillary  bronchitis,  or 
bronchopneumonia.  I  believe  that  a  thin,  light,  warm  flaxseed  poultice 
spread  over  the  back  and  chest  of  the  child  and  covered  with  oil-silk,  is  a 
remedy  of  the  very  greatest  value  in  preventing  the  extension  of  this 
disease.  Poultices,  when  properly  used  in  connection  with  the  open-air 
treatment,  do  not  make  the  child  uncomfortable  or  increase  its  tempera- 
ture ;  on  the  other  hand,  they  are  sedative,  rather  than  irritating,  but  they 
can  be  successfully  managed  only  when  the  patient  is  under  the  care  of 
nurses  who  understand  how  to  make  and  how  to  apply  them  without  un- 
necessarily exposing  the  infant  to  draughts  of  cold  air.     It  has  been  my 


TREATMENT  469 

practice  to  change  the  poultices  at  intervals  of  two  hours,  and  when  this 
is  done  the  patient  is  carried  for  a  few  minutes  from  the  cold  room  into 
an  adjoining  room,  and  as  soon  as  the  poultice  is  adjusted  he  is  imme- 
diately returned  to  his  fresh-air  chamber.  The  poultice  is  of  especial  value 
in  the  very  onset  of  bronchopneumonia,  and  is  to  be  used  only  during  the 
time  the  disease  is  progressing.  The  oil-silk  jacket  lined  with  a  thin 
layer  of  cotton-wool  may  be  used  where  the  poultice  cannot  be  satisfactorily 
handled,  and  it  may  be  substituted  for  the  poultice  after  its  discontinuance. 
After  many  years  of  experience  with  the  oil-silk  jacket  and  the  poultice, 
I  am  to-day  a  firm  believer  in  their  efficacy,  and  think  they  are  the  most 
important  agents  we  have  for  stopping  the  spread  of  bronchopneumonia 
in  its  early  stages.  I  fail  to  see  what  possible  harm  they  can  do  when 
combined  with  the  open-air  treatment  of  this  disease.  I  have,  in  connec- 
tion with  the  oil-silk  jacket,  for  many  years  used  the  following  prescrip- 
tion, which  is  to  be  applied  as  an  inunction  to  the  chest  of  the  child  twice 
in  twenty-four  hours : 

Guaiacoli 3  i 

Lanolini    anhydrous    q.  s.  ad    5  i 

One-half  level  teaspoonful  applied  as  an  inunction  to  the  chest  twice 
a  day. 

This  guaiacol-lanolin  prescription,  when  well  rubbed  in,  is  readily  ab- 
sorbed, the  guaiacol  appearing  in  the  urine  within  two  hours  after  its 
application.  The  guaiacol  thus  administered,  while  it  may  never  reach 
the  pulmonary  mucous  membrane,  certainly  acts  as  a  lymphatic  antiseptic, 
and  as  it  passes  from  the  skin  through  the  lymphatics  it  may  favorably 
influence  the  lymphatic  involvement  which  always  occurs  in  bronchopneu- 
monia. This  drug,  administered  in  this  way,  is  of  especial  value  in  those 
cases  complicated  by  lymphatic  or  pulmonary  tuberculosis. 

Treatment  During  Convalescence. — Following  the  disappearance  of 
the  acute  symptoms,  there  is  usually  a  period  of  slow  convalescence;  the 
child  is  weak,  nervous  and  anemic.  During  this  time  the  fresh-air  treat- 
ment is  to  be  continued,  and  a  carefully  selected  diet  suitable  to  the  nu- 
tritional demands  of  the  child  prescribed.  One  of  the  thick  malt  extracts 
combined  with  cod-liver  oil  or  iron,  or  some  form  of  arsenic,  or  syrup  of 
the  iodid  of  iron,  or  hydriodic  acid,  may  be  valuable  tonics  during  this 
period.  In  children  predisposed  to  tuberculosis  creosote,  or  the  benzoate 
or  carbonate  of  guaiacol  may  be  given  with  benefit. 


470  PLEUKISY 

CHAPTER    LIII 
PLEURISY 

Pleurisy  is  an  inflammation  of  the  pleura,  usually  secondary  to  infec- 
tion elsewhere,  most  commonly  in  the  lungs.  This  inflammation  may 
occur  either  without  or  with  effusion  into  the  pleural  cavity.  The  former 
is  called  dry  pleurisy.  The  latter  occurs  in  two  forms,  the  serofibrinous 
and  purulent,  depending  upon  the  character  of  the  exudate;  these  are  fre- 
quently commingled,  the  case  beginning  as  a  serous  and  later  becoming  a 
purulent  pleurisy.  The  dry  form  is  .not  so  infrequent  as  clinical  records 
would  indicate;  it  is  commonly  overlooked,  being  masked  by  the  accom- 
panying pneumonia,  or  other  causative  disease.  The  purulent  form  (em- 
pyema) is  both  relatively  and  actually  much  more  common  in  the  child 
than  in  the  adult. 

Etiology. — Infection  with  pathogenic  microorganisms  is  the  cause  of 
this  disease.  In  infancy  and  childhood  the  pneumococcus  is  the  common 
cause;  this  is  especially  true  of  the  purulent  form  (empyema).  Koplik 
found  this  organism  in  75  per  cent,  of  his  cases;  Xetter,  Beck,  and  other 
investigators  report  similar  findings.  The  percentage  of  cases  due  to  the 
pneumococcus  is  greatest  in  infancy,  and  slowly  diminishes  with  advancing 
childhood.  Infantile  empyema  is  nearly  always  due  to  this  organism,  while 
in  the  adult  only  about  25  per  cent,  of  the  cases  are  due  to  this  cause. 
Streptococci  and  staphylococci  are  the  next  most  common  organisms  asso- 
ciated with  pleurisy;  these  cases  usually  occur  as  septic  complications  of 
the  acute  infectious  diseases;  they  are  not  as  common  in  the  infant  and 
young  child  as  in  the  older  child  and  adult.  Of  special  interest  is  the  fact 
that  tubercle  bacilli  are  much  less  frequently  a  cause  of  pleurisy  in  the  in- 
fant and  young  child  than  in  the  adult.  Tuberculous  pleurisy  is  a  com- 
paratively common  disease  in  adult  life,  while  in  childhood  only  about  4  or 
5  per  cent,  of  the  cases  are  due  to  this  cause.  In  a  fair  percentage  of  tuber- 
culous pleurisies  neither  the  tubercle  bacillus  nor  other  microorganisms 
can  be  demonstrated  in  the  fluid.  Negative  findings  in  the  purulent  exu- 
date are  suggestive  of  tuberculosis,  but  even  when  these  negative  cases  are 
included  the  percentage  of  tuberculous  pleurisies  remains  as  low  as  above 
stated.  Other  microorganisms,  such  as  the  typhoid,  colon,  and  influenza 
bacilli,  may  produce  pleurisy,  but  these  cases  are  relatively  rare. 

Pleurisy  may  be  a  primary  disease,  but  in  the  vast  majority  of  the 
cases  it  is  secondary.  The  primary  cases  are,  usually,  the  first  manifesta- 
tions of  a  rheumatic  or  pneumococcic  infection.  The  secondary  cases,  for 
the  most  part,  are  associated  with  or  occur  as  complications  of  lobar 
pneumonia,  bronchopneumonia,  or  acute  bronchitis.  The  various  acute  in- 
fectious diseases,  especially  rheumatism,  influenza,  scarlet  fever,  diphtheria, 
follicular  tonsillitis,  measles,  whooping-cough,  typhoid  fever,  tuberculosis. 


PATHOLOGY  471 

chronic  gastroenteritis  and  septicopyemia,  may  produce  pleurisy.     In  the 
new-born  sepsis  is  the  most  important  cause. 

Pleurisy  is  most  commonly  seen  between  the  sixth  month  and  the  sixth 
year,  and  occurs  with  diminishing  frequency  before  and  after  this  period. 
The  serofibrinous  type  is  occasionally  observed  in  the  infant,  becomes 
more  common  after  the  third  year,  and  occurs  with  increasing  frequency 
from  this  time  on,  so  that  in  later  childhood  and  adult  life  it  is  much 
more  common  than  purulent  pleurisy. 

Pleurisy  occurs  more  frequently  in  boys  than  in  girls,  and  is  much 
more  prevalent  during  the  cold,  damp  months  of  winter  and  spring  than 
it  is  in  the  warmer  and  dryer  months.  Exposure  to  damp,  cold  weather  or 
"catching  cold"  is  perhaps  an  important  exciting  cause,  which  can  act, 
however,  only  by  producing  a  more  favorable  soil  for  the  microorganisms 
which  cause  this  disease. 

Pathology. — On  post-mortem  examination  old  pleural  adhesions,  with 
more  or  less  marked  thickening  of  the  pleura,  may  be  found  in  children 
dying  of  other  diseases;  such  unsuspected  lesions  commonly  result  from 
the  dry  or  fibrinous  form  of  pleurisy.  In  this  form,  during  the  acute  * 
stage,  there  is  found  on  the  congested,  inflamed,  and  thickened  pleura  a 
fibrinoplastic  exudate,  with  perhaps  a  slight  amount  of  yellow  serum  in 
the  pleural  cavity.  The  rubbing  together  of  these  roughened  surfaces 
produces  the  characteristic  friction  rub.  The  effusion  and  exudate  in  these 
cases  are  absorbed,  leaving  the  pleural  surfaces  adherent  or  bound  together 
by  fibrinous  bands  at  certain  points.  These  adhesions,  however,  produce 
little  or  no  damage,  since  they  do  not  to  any  extent  interfere  with  lung 
expansion. 

Pleurisy  with  effusion  presents  a  very  different  pathological  picture. 
Whatever  may  be  the  character  of  the  effusion,  the  lung  is  pressed  up- 
ward until  there  is  very  little  expansion  on  the  affected  side.  The  pleural 
cavity  in  these  cases  is  filled  with  serous,  seropurulent  or  purulent  fluid, 
which,  in  a  small  percentage  of  cases,  is  tinged  with  blood.  Not  infre- 
quently this  exudate  is  encapsulated  and  thereby  separated  from  the  rest 
of  the  pleural  cavity,  or  in  rare  instances  more  than  one  encapsulated 
sac  of  fluid  may  be  held  between  the  pleural  surfaces,  so  that  the  tapping 
of  one  of  these  cavities  does  not  reach  the  other.  In  properly  treated  cases, 
especially  those  in  which  the  fluid  is  serous,  complete  disappearance  of 
the  effusion  may  be  obtained  with  comparatively  little  damage  to  the 
pleural  cavity,  and  with  little  or  no  diminution  of  the  respiratory  capacity 
on  the  affected  side.  The  lung  in  these  cases  refills  the  chest  cavity,  and 
the  resulting  pleural  adhesions  have  little  or  no  influence  in  impeding 
respiratory  movements.  In  other  cases,  more  especially  in  empyema,  there 
is  great  danger  that  extensive  pleural  adhesions  will  not  only  obliterate 
the  pleural  cavity,  but  that  the  lung  on  the  affected  side  may  remain  in 
a  state  of  partial  shrinkage  due  to  the  inflammatory  adhesions.  In  such 
instances  the  respiratory  capacity  of  the  lung  may  be  greatly  diminished 
and  the  resultant  deformity  of  the  chest  and  spine  be  very  great.     Un- 


472  PLEUEISY 

treated  cases  of  empyema  may  ulcerate  either  through  the  parietal  or 
visceral  pleura,  on  the  one  hand  producing  a  subcutaneous  abscess,  or 
on  the  other  discharging  the  pus  into  the  bronchial  tubes.  The  quantity 
of  fluid  may  reach  from  1,000  to  4,000  c.  c. 

Symptomatology. — General  Symptoms. — Pleurisy  is  commonly  mani- 
fested by  fever,  cough,  pain  in  the  chest,  disturbances  of  respiration  and 
rapid  pulse.  Any  or  all  of  these  symptoms  may  be  absent  in  individual 
cases,  but  on  the  whole,  in  well-marked  pleurisy,  especially  where  there  is 
an  effusion  in  the  pleural  cavity,  this  symptom  group  in  whole  or  part  is 
present,  aiid  with  it  headache,  vomiting  and  constipation  are  not  infre- 
quently associated. 

In  the  most  common  group  of  cases,  those  following  lobar  or  broncho- 
pneumonia, the  pneumonia  usually  runs  its  course  with  its  characteristic 
symptoms,  but  following  the  fall  in  temperature  between  the  seventh  and 
the  tenth  day  the  patient  fails  to  convalesce,  there  are  a  secondary  rise  of 
temperature,  an  aggravation  of  the  cough,  sharp  pain  in  the  chest,  in- 
creasing dyspnea,  rapid  pulse,  and  a  careful  physical  examination  reveals 
a  beginning  pleurisy.  In  other  instances  the  pleurisy  supervenes  during 
the  pneumonia,  and  may  become  at  once  the  dominant  symptom  group; 
in  these  cases  the  prolongation  of  the  fever  with  the  cough,  dyspnea,  pain 
in  the  chest  and  rapid  pulse  are  important  symptoms  indicating  this  com- 
plication. The  fever  may  reach  104°  or  105°F.,  and  the  pulse  may  run 
above  160.  In  another  group  of  cases,  much  less  common,  the  pleurisy 
appears  as  a  primary  disease;  in  this  variety  the  patient  is  taken  suddenly 
ill  with  headache,  vomiting,  and  chilliness,  and  the  fever  rises  to  102° 
or  103°r.,  and  the  hacking  cough,  pain  in  the  chest  and  shallow,  rapid 
breathing  quickly  develop.  In  still  another  group  of  cases  the  disease  is 
not  announced  by  acute  symptoms;  the  child  for  a  week  or  ten  days  is 
languid,  has  perhaps  a  slight  cough,  little  or  no  appetite,  gradually  loses 
strength,  becomes  more  or  less  anemic,  has  a  slight  intermittent  fever, 
with  more  or  less  marked  night  sweats,  and  during  this  time,  while  it  is 
clearly  evident  that  the  child  is  ill,  there  may  be  little  to  call  attention  to 
the  fact  that  he  has  a  well-marked  pleurisy  with  an  effusion  in  the  pleural 
cavity.  The  character  and  even  the  location  of  the  disease  in  such  cases 
are  finally  revealed  by  physical  examination  of  the  chest. 

Individual  Symptoms. — The  fever  in  the  serofibrinous  form,  while 
it  may  be  high  in  the  beginning,  quickly  subsides  and  runs  an  irregular 
course,  reaching  101°  or  102°  F.  Under  proper  treatment  it  usually 
becomes  normal  within  a  week  or  ten  days.  In  empyema  the  fever  is 
irregularly  intermittent  or  remittent,  rising  to  104°  or  105 °F.,  and  fre- 
quently falls  to  normal  or  below  normal ;  when  due  to  pneumococcic  infec- 
tion the  variations  in  temperature  are  not  so  marked,  but  when  due  to 
sepsis  following  the  acute  exanthemata  it  is  characterized  by  rapid  rises 
and  falls,  and  is  commonly  associated  with  sweating.  Following  drainage 
of  the  pleural  cavity,  it  should  run  a  mildly  intermittent  course  until 
convalescence  is  established. 


SYMPTOMATOLOGY 


473 


Pain  in  the  side  of  the  chest  aggravated  by  coughing  and  by  deep 
inspirations,  is  one  of  the  most  significant  and  valuable  symptoms.  It  calls 
attention  to  the  location  and  na- 
ture of  the  disease.  The  "stitch" 
in  the  side  is  an  early  symptom 
Avhich  usually  disappears  when  the 
effusion  has  increased  sufficiently 
to  have  separated  the  pleural  sur- 
faces. It  should  also  be  remem- 
bered that  in  young  children  the 
pain  caused  by  coughing  and  in- 
spiration is  not  infrequently  re- 
ferred to  the  abdomen. 

The  cough  is  irritating,  dry, 
hacking  and  painful,  and  the  pa- 
tient makes  an  effort  to  suppress 
it.  The  anxious,  worried,  and 
pained  expression  which  spreads 
over  the  face  of  the  child  when  it 
feels  it  can  no  longer  suppress  the 
cough  is  very  suggestive  of  pleu- 
risy. With  the  appearance  of  the 
effusion,  the  cough  may  become 
less  painful  and  less  frequent. 

Respiration  is  more  or  less 
painful,  and  the  child  breathes 
superficially  so  as  to  limit  the 
chest  expansion.  The  respiratory 
movements  are  rapid  and  are  ac- 
companied by  grunting;  dyspnea 
is  usually  a  gradually  increasing 
symptom,  which  after  a  time  be- 
comes very  marked.  In  its  efforts 
to  suppress  respiratory  movements 
on  the  diseased  side  the  child  lies 
on  the  affected  side,  and  makes  the 
unaffected  lung  do  as  much  of  the 
work  as  possible;  this  attitude  is 
most  suggestive  and  characteristic, 
x\s  the  pleural  cavity  fills,  the 
respiratory  movements  are  less 
painful,  but  the  dyspnea  and  rapid 
breathing  are  more  marked. 

In  left-sided  pleurisy  with  ef- 
fusion, the  heart  is  displaced  and  impeded  in  its  action  by  the  accumulating 
fluid.     In  these  cases  the  pulse,  which  is  at  all  times  rapid,  may  reach 


FAHRENHEIT    TEMPERATURE 

40CDC0O         a^ooooo 

•^^      OO^       CO^     ^       —^      »0^      CO        **^      en        OS       "-* 

o 

is 

r 

O 

h 

z-< 

3 

- 

3 

— "  ~ 

«, 

J3 

- 

CO 

S 

. 

v^ 

^ 

K) 

en 

Ol 

05 

»o 

i 

— 

— 

-. 

S 

Li«: 

»• 

— 

— 

C9 

cs 

CO 

s 

5 

2 

r' 

l^S- 

~ 

- 

^ 

KJ 

CO 

CO 

^a 



r? 





^ 



•« 

r- 

' 

— 

~ 

=» 

-'- 

03 

=, 

H 

Jl 













— 

OS 

= 

10 

«o 









^a 

— 



'*'- 

— 

— 

ro 

'1^ 

»o 

^ 







NJ 



zz 

— 



— 

— 

JO 

«; 

o> 

m 

13 

:z 



i 

— 

— 

oo 

oo 

-  — 

^- 

— 

— 

!S 

CO 

— 

^- 

iS" 

— 

— 

^ 

fO 

— 

is— 

— 

— 

CO 

2 

3 



;:::: 

::::; 

= 

^ 

= 

= 

s 

s 



-== 

^,- 

— 

— 

s 

ui 

en 

g 









7—. 

»i" 

— 

— 

y 

• 

z' 

oo 

OO 



-Si  = 

-^ 

— 

— 

' 

^^. 

m 

m 

CO 

s 

- 

•< 

lO 

N> 

1 





rS 

CO 

— 

— ?■ 

— 

— 

S 

»i 

^» 

*  . 

g; 

cr 

— t 







S; 

m 

' 

5  - 

^  =J 

— 

— 

^ 

> 

. , 





S; 

OO 





— 

— 

<o 

CO 





474 


PLEURISY 


150  to  180,  and  is  commonly  feeble.     In  severe  cases  cyanosis  is  present. 
With  the  progress  of  the  disease  there  is  more  or  less  marked  facial  pallor, 


FAHBENHEIT    TEMPERATURE 

s    s   s  i    i    S   S    2   §   i  5 

o 

O 

ZO 
05 

-i 

I 

AHRENHEIT     TEMPERATURE 

<o      C3^     — ^     lo     CO      Xfc      en      <n    S 

0 

> 

0 

H 
I 

S 

^ 

:^ 

zz:: 

=r 

rrr 

— 

— 

' 

z=: 

=z 

zzz 

-J- 

-=- 

— 

= 

: 

— 

— 

— 

75 
76 

-=- 

— 

^i: 

s — 

:=: 

^ 

T 

77 

5 

5 

s 

1 

78 
79 
BO 
81 
M 
83 

"bT 

86 

X 

e 

9 
11 

18 



i 

-— 

— - 

— - 

= 

:E 

^ 

1 

1 

= 

= 

= 



^ 

~ 

= 

= 

= 

= 

88 
89 
90 
91 
92 
93 
9" 
95 
9« 

^ 

13 

1 

= 

— 

1 

1 

^ 

1 

16 

80 
81 

83 

? 

• 

li 

^ 

' 

97 
98 
99 
100 

4 

;| 

= 

^ 

= 

25 

26 

87 
88 

4 

^ 

^ 

^ 

S 

^ 

101 
lOa 

104 

o» 

^~- 

3 

g 

^ 

~~^ 

1 

•~~ 

1 

29 

30 

":;" 

1 

= 

= 

= 

= 

105 
106 

108 

_5 

1 

— 

1 

^ 

= 

= 

= 

= 

33 

i 

^ 

= 

= 

= 

= 

110 
11? 

f 

= 

1 

^ 

^ 

= 

= 

38 
39 

-r 

t!= 

S= 

=z 

=r 

=: 

ZIZ 

in. 



^ 

: 

: 

^ 

-!!_ 

=^ 

= 

— 

— 

— ■ 

116 

?=:; 

— 

— ; 

— 

"T 













117 

g 

7^* 



1 

^ 

1- 

^^ 

~~— 

118 

■^ 



— 

T 

119 

2 

47   r 

120 
181 
122 
123 

1 

w 

s 

48      Z 

50  ;: 

^ 

= 

z= 

— 

— 

^ 

— 

1 

= 

z= 

= 

= 

= 

m 

187 
188 
189 
130 

1 

1 

= 

= 

il 
57 

58 

-1- 

§ 

^ 

EE 

= 

— 

1 

— 

131 
138 

135 
116 

137 

0 

i 

s 

— 

= 

= 

= 

59 
60 
61 
62 
63 

.» 

■ 

S 

= 

= 

= 

= 

^^ 

139 
KO 

148 

143 

4^ 

^ 

E 

s 

^ 

i 

= 

= 

= 

67 
68 
69 

70 

72 

^ 

especially  about  the  lips,  and  the  child  gradually  grows  more  anemic  and 
emaciated. 


SYMPTOMATOLOGY  475 

In  pleurisy  with  effusion  the  following  points  are  revealed  by  physical 
examination:     Inspection  shows  diminished  respiratory  movements  on  the 
affected  side,  and  this  side  of  the  chest  appears  larger  and  the  intercostal 
spaces  are  less  e\ident.     Palpation  may  show  that  the  vocal  fremitus  is 
diminished  or  lost  over  that  portion  of  the  chest  which  is  filled  with  fluid ; 
in  extensive  effusions  it  cannot  be  felt  over  the  whole  of  the  lower  portion 
of  the   chest  cavity.      Palpation   also   reveals  the   diminished   respiratory 
movement  of  the  affected  side  and  the  increased  movements  on  the  well 
side.    In  left-sided  pleurisy  it  reveals  the  displaced  apex  beat,  and  in  right- 
sided  pleurisy  the  lower  border  of  the  liver  may  be  felt  pushed  somewhat 
downward  into  the  abdominal  cavity.     Percussion  gives  the  most  valuable 
information.     With  the  child  sitting  in  an  upright  position  one  can,  as  a 
rule,  outline  the  fluid  by  the  dullness,  which  in  most  instances  amounts  to 
flatness,  over  that  portion  of  the  chest  cavity  filled  with  fluid.     Directly 
above  the  line  of  dullness  the  resonant  note  of  the  lung,  which  may  be 
almost  tympanitic,  is  elicited.     In  many  instances  the  upper  line  of  dull- 
ness shifts  with  the  position  of  the  child,  being  affected  by  gravitation  of 
the  fluid.     From  the  standpoint  of  diagnosis  the  peculiar  resistance,  which 
is  felt  by  the  percussing  finger,  is  second  only  in  importance  to  the  dull- 
ness or  flatness  obtained  by  percussion.     These  two  signs  rank  all  others 
in  value  in  the  diagnosis  of  pleurisy,  and  they  alone  justify  the  introduc- 
tion of  an  exploring  needle  to  ascertain  not  only  the  presence,  but  the 
character,  of  the  pleural  effusion.     It  should  be  remembered  that,  while 
the  flatness  elicited  by  percussion  is  commonly  found  in  the  lower  portion 
of  the  chest,  especially  posteriorly,  it  may  also  be  found  in  other  parts 
of  the  chest,  being  there  produced  by  encapsulated  fluid,  and  that  the 
dullness  elicited  over  these  encapsulated  areas  may  not  amount  to  absolute 
flatness.     In  some  instances,  especially  when  the  encapsulated  fluid  exists 
along  the  back  of  the  lung,  one  may  on  deep  percussion  obtain  a  slightly 
resonant  note  from  the  lung  situated  beyond  the  fluid.     Attention  should 
also  be  directed  to  the  fact  that  where  the  pleural  cavity  is  filled  with 
fluid,  and  the  lung  is  pressed  upward  and  forward,  a  very  resonant  tym- 
panitic note  may  be  obtained  at  the  apex  anteriorly,  while  all  the  re- 
maining portion  of  the  chest  is  flat  on  percussion  and  gives  a  peculiar 
board-like  resistance  to  the  percussing  finger.     In  these  cases  of  extensive 
effusion  the  dullness  extends  be^'ond  the  opposite  border  of  the  sternum. 
Auscultation  is  of  much  less  value  than  percussion.    Early  in  the  disease, 
however,  one  may  be  able  to  hear  the  characteristic  friction  rub  which 
coincides  with  inspiration,  or  expiration,  or  with  both.     The  to-and-fro 
friction  rub,  when  it  can  be  heard,  is  a  sign  of  great  value.    It  disappears 
early  with  the  increase  of  effusion  and  is  heard  again  more  distinctly  when 
the  fluid  almost  or  quite  disappears.    Over  the  fluid  the  respiratory  sounds 
are  absent,  indistinct,  or  distant,  but  on  the  whole  the  auscultatory  find- 
ings in  pleurisy  with  effusion  are  very  unsatisfactory  and  at  times  mislead- 
ing.    This  applies  especially  to  infants  and  young  children.     Bronchial 
breathing,  bronchophony,  and  even  respiratory  sounds  may  be  heard  over 
areas  containing  fluid. 


476  PLEUEISY 

Displacement  of  Other  Organs. — In  left-sided  pleurisy  with  effusion 
the  displacement  of  the  apex  beat  of  the  heart  toward  the  median  line  is 
one  of  the  most  valuable  findings;  it  may  be  pushed  over  as  far  as  the 
sternum.  In  right-sided  pleurisy  the  displacement  of  the  liver  downward, 
when  it  can  be  clearly  demonstrated,  is  a  valuable  sign. 

Fluoroscopic  examinations  or  X-ray  pictures  may  locate  the  fluid,  show 
displacement  of  the  heart  and  other  organs  and  thereby  give  valuable  di- 
agnostic information. 


Fig.  77. — Pleural  Effusion  in  Left  Side  of  the  Chest. 

Exploratory  Puncture. — The  ultimate  diagnosis  and  also  the  prognosis 
will  largely  depend  on  the  results  of  an  exploratory  puncture.  This  should 
be  made  at  a  point  over  the  area  of  greatest  dullness  and  where  there  is  an 
almost  or  complete  absence  of  fremitus.  In  cases  where  the  flatness  is 
extensive  the  point  chosen  should  be  over  the  lower  portion  of  this  area. 
In  the  average  case,  where  the  whole  lower  portion  of  the  pleural  cavity  is 
filled  with  fluid,  the  point  of  selection  should  be  the  posterior  axillary  line, 
at  the  sixth  interspace  on  the  left  side  and  the  fifth  interspace  on  the  right. 


SYMPTOMATOLOGY  477 

111  exceptional  cases  encapsulated  fluid  will  he  found  over  other  areas,  and 
the  lower  portion  of  the  pleural  cavity  will  be  free  from  fluid,  so  that  the 
physical  examination  must  in  every  case  determine  the  point  for  intro- 
ducing the  needle.  The  child' is  firmly  held  in  a  sitting  position,  the  skin 
is  thoroughly  cleansed,  and  a  clean  needle,  attached  to  a  syringe,  is  in- 
troduced from  1  to  2  cm.  until  it  reaches  the  pleural  cavity.  The  piston 
is  then  gently  drawn  and  the  fluid,  if  it  be  reached  by  the  needle,  will 
flow  into  the  syringe.  If  fluid  is  not  obtained  it  should  not  be  sought  for 
by  moving  the  point  of  the  needle  in  the  pleural  cavity,  but  it  should  be 
immediately  withdrawn;  after  a  second  careful  physical  examination,  to 
again  determine  the  point  of  greatest  flatness,  the  skin  and  needle  should 
again  be  cleaned  and  the  needle  introduced  in  this  place  in  the  hope  of 
striking  fluid.  In  making  this  exploratory  puncture  a  needle  of  fair 
size  (one  millimeter)  should  be  used,  as  a  smaller  one  is  likely  to  be- 
come clogged  by  pus  or  fibrin.  It  should  pass  well  under  the  border  of 
the  rib  to  avoid  injuring  the  intercostal  artery  which  runs  along  the 
inner  and  lower  border  of  the  rib.  The  wound  left  by  the  introduction 
of  the  needle  should  be  immediately  covered  with  adhesive  plaster.  There 
is  almost  no  danger  from  an  exploratory  puncture  when  it  is  made  through 
a  clean  skin  with  a  sterile  needle  unless  it  be  pushed  through  the  pleural 
cavity  into  an  infected  lung,  and  this  danger  is  rather  remote.  It  is  also 
important  to  avoid  the  cardiac  region  as  much  as  possible  so  as  not  to 
wound  the  pericardium.  The  character  of  the  pleurisy  is  determined  by 
the  fluid  obtained  by  this  exploratory  puncture;  it  may  be  serous,  sero- 
fibrinous, seropurulent,  or  purulent  in  character  and  may  contain  blood. 
A  careful  bacteriological  examination  of  the  fluid  thus  obtained  may  de- 
termine the  character  of  the  infection.  If  the  bacteriological  examina- 
tion shows  the  pneumococcus  to  be  the  dominant  or  sole  microorganism 
present,  the  prognosis  is  better  and  the  disease  will  run  a  milder  course 
than  in  those  cases  in  which  streptococci  and  staphylococci  are  found  in 
abundance."  Tubercle  bacilli  are  rarely  found  in  the  fluid,  not  only  be- 
cause tuberculous  pleurisy  is  comparatively  rare  in  childhood,  but  also 
because  even  in  cases  due  to  tuberculosis  the  tubercle  bacilli  are  not  readily 
found.  Inoculation  experiments  with  guinea-pigs  may  be  resorted  to  in 
chronic  cases  in  which  tuberculosis  is  suspected.  If  the  fluid  be  of  light 
yellow  color  and  serous  in  character  the  probabilities  are  that  the  disease 
will  remain  a  serous  pleurisy;  this  inference  is  especially  true  in  children 
over  five  years  of  age,  since,  at  this  time  of  life,  this  form  of  pleurisy 
is  much  more  common.  If,  however,  the  serous  fluid  is  found  on  mi- 
croscopical examination  to  contain  pneumococci,  streptococci,  or  staphylo- 
cocci, and  if,  at  the  same  time,  it  contains  a  considerable  number  of 
lymphocytes  and  pus  cells,  the  probabilities  are  that  this  serous  pleurisy  will 
in  a  short  time  be  converted  into  an  empyema;  this  inference  is  especially 
true  in  young  children  under  five  years  of  age,  since  at  this  period  purulent 
pleurisy  is  the  most  common  form.  The  effusion,  both  in  serous  and 
purulent  pleurisy,  may  be  tinged  with  blood,  but  this  is  of  little  diagnostic 


478  PLEUBISY 

or  prognostic  importance.  In  the  adult,  blood  i»  an  unfavorable  sign,  since 
it  commonly  means  tuberculous  pleurisy,  but  this  is  not  true  in  the  child. 
At  this  age  tuberculous  pleurisy  may  occur  without  the  fluid  being  tinged 
with  blood,  and  again  the  effusion  may  be  bloody  in  other  forms  of  pleurisy. 
The  presence  of  blood  therefore  in  the  young  child  is  of  little  importance 
nnless  it  occurs  in  low  forms  of  pleurisy  associated  with  hemorrhagic 
diseases,  such  as  scurvy. 

Treatment. — The  fresh-air  treatment  is  quite  as  important  in  pleurisy 
as  it  in  in  pneumonia;  apart  from  this,  the  disease  should  be  treated 
symptomatically.  In  serous  pleurisy,  or  in  those  cases  in  which  the  char- 
acter of  the  fluid  has  not  been  determined,  the  treatment  for  the  time 
being  is  largely  expectant-  The  patient  is  put  to  bed,  and,  if  he  be  under 
two  years  of  age,  his  diet  should  be  liquid  in  character  and  carefully 
selected  to  suit  his  diminished  digestive  capacity.  In  older  children  suf- 
fering from  serous  pleurisy  the  diet  should  be  as  dr}-  as  possible  but 
should  fully  meet  nutritional  demands.  It  is  wise  to  give  as  little  liquid 
as  possible;  milk,  water,  and  soups  should  be  sparingly  used;  meat,  eggs, 
cereals,  and  bread,  with  a  minimum  amount  of  milk^  furnish  a  nu- 
tritious diet,  and  one  that  is  believed  to  promote  the  absorption  of  the 
serum  in  the  pleural  cavity.  Saline  laxatives  are  advisable  and  diuretics, 
such  as  acetate  of  potash  and  diuretin,  may  he  given  in  doses  suited  to 
the  age  of  the  child;  these  remedies,  however,  apply  to  the  child  and 
not  to  the  infant.  In  the  infant  the  disease  is  commonly-  purulent,  and, 
even  when  it  is  not,  the  remedies  above  mentioned  can  do  no  good.  A 
cardiac  tonic,  such  as  tincture  of  strophanthus  or  tincture  of  digitalis, 
should  be  given  in  every  case.  In  empyema  it  serves  as  a  supporting 
measure  to  the  heart,  and  in  serous  pleurisy,  by  improving  the  circulation 
and  acting  as  a  diuretic,  it  promotes  the  absorption  of  the  fluid.  Whiskey 
should  be  given  as  long  as  the  septic  temperature  continues.  Sodium 
salicylate  (from  oil  of  wintergreen),  or  aspirin,  in  doses  suited  to  the 
age  of  the  child,  are  valuable  in  serous  pleurisy  but  not  in  empyema.  The 
salicylates  are  especially  indicated  in  children  of  gouty  or  rheumatic  pa- 
rentage. 

Paregoric,  codein,  or  some  other  preparation  of  opium  may  be  neces- 
sary to  relieve  the  pain  in  the  side,  although  it  is  advisable  to  avoid 
their  use  as  long  as  possible;  they  are  perhaps  never  indicated  in  the 
treatment  of  this  disease  in  infants  under  eighteen  months  of  age.  In 
older  children,  however,  when  judiciously  used,  they  may  be  of  value  in 
relieving  the  pain  in  the  side  or  the  irritating  and  paroxysmal  cough  which 
prevents  sleep  and  increases  nervous  irritation.  The  sharp  paiu,  which 
is  aggravated  by  the  cough  and  by  respiratory  movements,  may  sometimes 
be  greatly  modified  by  strapping  the  chest  wall  with  adhesive  plaster,  or, 
as  Jacobi  recommends,  by  fastening  a  tight  towel  bandage  around  the 
entire  chest.  Counter-irritation  with  mustard  paste  or  mustard  plasters 
is  also  very  generally  recommended  for  the  relief  of  pain.  With  the 
onset  of  the  disease  cold  applications  in  the  form  of  an  ice-bag  wrapped 


TREATMENT  479 

in  a  towel  may  be  applied  to  the  affected  side;  later,  hot  fomentations 
or  hot   poultices  give  more  relief. 

Certain  medicines,  given  by  inunction,  such  as  guaiacol  one  drachm, 
to  one  ounce  of  anhydrous  lanolin,  may  be  used  to  advantage.  This 
ointment  is  to  be  thoroughly  rubbed  in,  and  then  a  warm  poultice  ap- 
plied; it  is  of  special  value  in  tuberculous  cases.  lodin  and  salicylic  acid 
may  also  be  given  by  inunction,  and  are  to  be  used  in  the  strength  of  one 
drachm  to  the  ounce  of  anhydrous  lanolin.  These  ointments  are  readily 
absorbed  and  pass  directly  into  the  lymph  and  blood  channels;  this  is 
the  only  manner  in  which  these  drugs  should  be  given  to  children  under 
three  years  of  age,  since,  when  given  in  this  way,  they  are  more  effective 
and  do  not  disturb  the  gastrointestinal  organs. 

Aspiration  of  the  pleural  cavity  for  the  removal  of  the  fluid  in  serous 
pleurisy  is  not  only  a  curative  but  at  times  it  may  be  even  a  life-saving 
measure.  It  is  perhaps  not  advisable  to  resort  to  aspiration  in  every  case 
of  serous  pleurisy.  In  a  minority  of  these  cases  the  fluid  will  be  spon- 
taneously absorbed  and  a  satisfactory  convalescence  established  within  a 
period  of  three  weeks.  But,  on  the  other  hand,  it  should  be  remembered 
that  aspiration  can  do  no  harm,  promotes  convalescence,  and  diminishes 
the  number  of  permanent  adhesions.  Aspiration  is  demanded  when  the 
fluid  has  accumulated  in  sufficient  quantity  to  displace  the  heart  or  em- 
barrass its  action;  when  the  pleural  cavity  is  well  fllled  and  respiration  is 
embarrassed,  and  in  those  cases  in  which  the  fluid  does  not  commence 
to  diminish  in  quantity  during  the  second  week  of  the  disease.  The  in- 
crease or  diminution  in  the  quantity  of  fluid  may  be  determined  by  the 
physical  signs  previously  mentioned  and  by  careful  measurements  of  the 
affected  side.  If  the  tape  measure  shows  the  chest  to  be  increasing  in 
size  the  fluid  is  on  the  increase;  if  these  measurements  are  found  to  be 
decreasing  the  fluid  is  gradually  disappearing.  In  aspirating  the  pleural 
cavity,  the  Potain,  or  some  other  equally  good  aspirator,  is  to  be  used,  and 
the  aspirating  needle  must  be  large  enough  to  allow  a  free  flow  of  pus 
through  it.  In  introducing  the  needle  the  same  antiseptic  precautions 
are  to  be  observed  as  have  been  described  above  for  the  exploratory  puncture. 
A  sterile  needle  is  to  be  introduced  through  the  thoroughly  cleansed 
skin,  at  a  point  where  the  exploratory  puncture  has  located  the  serous 
exudate.  It  is  well  to  introduce  the  needle  just  above  the  lower  line  of 
absolute  flatness,  so  as  to  tap  the  low^er  portion  of  the  fluid-filled  sac.  A 
sufficient  quantity  of  serum  is  slowly  withdrawn  to  relieve  the  pressure 
on  the  heart  and  lung.  It  is  not  necessary,  neither  is  it  wise,  to  with- 
draw all  of  the  fluid;  if  the  greater  part  is  removed  the  remainder  will 
probably  be  absorbed.  In  some  instances  it  may  be  necessary  to  aspirate 
a  second  time.  If,  during  the  removal  of  the  fluid,  the  patient  complains 
of  being  faint,  if  the  heart  action  becomes  very  weak,  if  a  violent  attack 
of  coughing  occurs,  or  if  other  uncomfortable  symptoms  supervene,  the 
needle  is  to  be  immediately  withdrawn. 

Surgical  Treatment  of  Empyema. — When  pus  is  present  in  the 
32 


480  PLEURISY 

pleural  cavity  it  must  be  evacuated  at  once  by  an  incision  between  the  ribs 
or  preferably  by  a  more  radical  surgical  operation  which  comprehends  the 
resection  of  a  small  portion  of  one  or  more  ribs.  To  attempt  to  treat 
these  cases  by  aspiration  is,  in  most  instances,  a  dangerous  waste  of  time, 
yet  Murphy  advocates  that  the  pus  should  be  withdrawn  from  the  abscess 
cavity  by  the  introduction  of  a  needle,  and,  following  this  operation,  60 
c.  c.  of  a  2-per-cent.  solution  of  formalin  in  glycerin  be  injected  into  the 
cavity.  He  emphasizes  the  point  that  this  solution  should  be  at  least 
twenty-four  hours  old.  This  process  is  to  be  repeated  every  two  to  four 
weeks  until  the  fluid  drawn  off  becomes  serosanguinolent  and .  sterile ;  it 
will  then  be  absorbed.  In  very  young  children  an  intercostal  incision 
into  the  abscess  cavity,  of  sufficient  size  to  permit  the  insertion  of  a  drainage 
tube,  is  commonly  successful.  It  should  be  made  under  proper  antiseptic 
precautions,  as  low  down  over  the  pus  pocket  as  possible  so  as  to  facilitate 
proper  drainage.  This  simple  operation  may,  as  a  rule,  be  made  under  a 
local  anesthetic,  such  as  a  weak  solution  of  cocain,  injected  into  the 
superficial  layers  of  the  skin  at  the  site  of  the  operation.  In  introducing 
the  knife,  it  is  important  to  avoid  the  intercostal  artery  which  lies  along 
the  lower  border  of  the  rib.  Following  the  incision,  one  or  two  short 
drainage  tubes,  held  by  safety-pins,  should  be  inserted  into  the  cavity, 
and  drainage  may  be  facilitated  by  one  of  the  suction  methods  later  referred 
to,  or  the  site  of  the  operation  may  be  well  padded  with  gauze  to  absorb 
the  pus  and  a  light  bandage  applied  to  hold  it  in  position.  If  the  gauze 
method  of  dressing  is  used  it  should  be  removed  one  or  more  times  daily. 
If  the  drainage  is  good  a  satisfactory  recovery  commonly  results.  This 
is  especially  true  of  the  pneumococcic  form  of  empyema,  so  common  in 
young  children.  In  children  over  three  years  of  age,  as  well  as  in 
younger  children,  in  whom  the  above  simple  operation  is  not  successful, 
the  abscess  cavity  should  be  drained  by  the  excision  of  a  small  section  of 
one  or  more  ribs.  In  this  operation  the  periosteum  should  be  stripped 
back  and  the  incision  made  through  its  posterior  layer.  In  aggravated 
cases  it  may  be  necessary  to  make  a  rib  exsection  at  two  points  of  the 
chest,  anteriorly  and  posteriorly,  in  order  to  obtain  more  perfect  drainage. 
The  opening  or  openings  thus  made  should  be  large  enough  to  receive 
two  rubber  drainage  tubes,  and  through  these  the  cavity  may  be  irrigated 
with  ordinary  antiseptic  solutions  (not  peroxid  of  hydrogen).  The  op- 
eration of  preference,  however,  in  practically  all  cases  is  to  make  one  rib 
exsection  rather  low  down  over  the  pus  pocket,  insert  two  drainage  tubes, 
and  employ  light  continuous  suction  by  one  of  the  recently  devised  methods 
for  this  purpose.  In  this  way  the  pus  cavity  is  not  only  properly  drained 
but  the  lung  is  kept  in  a  state  of  expansion  and  sinuses  are  obliterated. 
Of  the  various  types  of  apparatus  devised  for  draining  the  abscess  cavity 
and  preventing  lung  collapse  the  following  are  the  simplest  and  most 
generally  applicable :  Bryant's  method,  in  which  a  deflated  Politzer  bag 
is  attached  to  the  drainage  tube  and  strapped  to  the  chest.  Brewer's 
method,   especially  applicable   in   young   children,   consisting   of   a   glass 


TEEATMENT 


481 


funnel,  securely  placed  against  the  chest  with  its  wide  mouth  covering  the 
drainage  tubes,  the  suction  being  secured  by  means  of  a  pump  connected 
by  a  rubber  tube  to  the  small  end  of  the  funnel. 

Collapse  of  the  lung  during  operation  may  be  prevented  by  Meltzer's 
method,  modified  by  Elsberg.  This  consists  in  pumping  air  into  the 
lungs  during  the  operation  for  empyema  through  a  tube,  considerably 
smaller  than  the  lumen  of  the  trachea,  passed  far  into  the  trachea  through 
the  glottis.  Under  this  method  the  air  enters  the  lung  through  the  tube 
and  escapes  around  the  tube,  and  sufficient  pressure  is  thereby  maintained 
to  prevent  collapse  of  the  lungs.  A  number  of  other  methods  have  been 
devised  having  the  same  object  as  the  Meltzer  method.  The  ideal  operation 
for  acute  empyema  would  be  to  evacuate  the  pus  b}  thoracotomy,  under 
a  method  which  would  hold  the  lung  close  to  the  chest  wall,  and  then 
apply  an  air-tight  dressing  or,  as  Eansohoff  suggests,  grasping  the  lung 
and  sewing  it  to  the  wound  margin  while  under  the  difEerential  pressure. 


Fia.  78. — James  Apparatus  for  Expanding  the  Lung. 

and  then  applying  one  of  the  suction  or  ordinary  drainage  methods  above 
described. 

Following  the  operation  the  lung  should  be  kept  as  quiet  as  possible 
for  four  or  five  days  and  then  should  be  encouraged  to  expand  by  active 
breathing  exercises,  or  by  the  use  of  the  apparatus  devised  by  James  for 
exj)anding  the  lung.  This  consists  of  two  bottles  connected  by  rubber 
tubing,  each  being  one-half  filled  with  fluid.  The  child  amuses  itself  by 
blowing  the  fluid  from  one  bottle  to  the  other  and  in  this  way  obtains  an 
excellent  pulmonary  exercise  which  assists  in  the  expansion  of  the  con- 
tracted lung. 

Bilateral  Empyema. — This  is  comparatively  rare,  but  when  it  does 
occur  the  left  side  should  be  operated  upon  first  and  the  opposite  side 
a  week  or  two  later.  When  rib  excision  is  performed  on  the  left  side  the 
right  side  may  be  aspirated,  and,  if  necessary,  this  aspiration  may  be 
repeated  from  time  to  time  to  prevent  the  accumulation  of  pus  in  quan- 
tities sufficient  to  seriously  impede  respiratory  movements. 

Chronic  Empyema. — Chronic  empyema  which  has  failed  to  respond 
to  surgical  methods  combined  with  the  fresh-air  treatment,  may  be  greatly 
benefited,  and,  in  some  instances,  convalescence  may  be  established  by  the 
use  of  autogenous  vaccines  as  described  in  the  chapter  on  Therapeutics  of 
Infancy  and  Childhood.     In  obstinate  cases  it  may  be  necessary  to  per- 


482  PLEUEISY 

form  decortication  of  the  lung,  as  recommended  by  Fowler,  removing  en 
masse  the  thickened  visceral  pleura  and  thus  allowing  the  lung  to  expand. 
Treatment  During  Convalescence. — Following  the  disappearance  of 
all  symptoms  in  empyema  all  forms  of  exercise  involving  the  arms  and 
chest  must  be  carefully  avoided.  The  child  should  live  and  sleep  in  the 
open  air  and  should  be  given  a  carefully  selected  diet  within  the  range 
of  its  digestive  capacity  and  tonics  containing  malt,  iron,  arsenic,  or  cod- 
liver  oil  may  be  indicated.  After  a  period  of  six  or  more  months,  when 
apparently  all  danger  of  a  return  of  empyema  has  disappeared,  the  pa- 
tient should  be  referred  to  an  orthopedic  surgeon  for  the  correction  of 
spinal  and  chest  deformities.  Properly  directed  breathing  and  gymnastic 
exercises  may  markedly  diminish  the  resultant  permanent  deformity. 


PLATE  V. 


V.  cava  superior 


Aorta  ascendens 


Foramen  ovale 

Valvula  venae  cavae 
[inferioris,  Eustachii] 

Atrium  dextrum 
Ventriculus  dexter 

V.  hepatica  sinistra 


Ductus  venosus 
[arantii) 


Distributions 
in  the  liver  - 


V.  portae 


V.  umbilicalis 


A.  umbilicales 


Arcus  aortae 


Ductus  arteriosus 
[BotalliJ 


Ramus  sinister 
A.  pulmonalis 


Aorta  abdominalis 


A.  iiiaca  communis 
V.  i'iaca  communis 


A.  iiiaca  externa 


A.  hypogastrica 


Vesica  urinaria 


Scheme  op  the  Circulation  of  the  Blood  in  the  Fetus 
(after  Spalteholz). 


SECTION   VIII 
THE   HEART 

The  heart  muscle  of  the  child  is  strong,  elastic,  and  bears  strain  with 
comparatively  little  injury,  not  only  because  of  the  very  great  elasticity 
of  the  muscle  cells  at  this  age,  but  also  because  the  elastic  tissue  surrounding 
these  cells  is  fully  developed  at  the  age  of  seven  (Fahr).  It  is  in  a 
state  of  growth  and  functional  development,  and  therefore  readily  under- 
goes hypertrophy  when  called  upon  to  do  more  than  the  normal  amount 
of  physiological  work  over  a  long  period  of  time. 

The  strength,  elasticity,  and  healthful  condition  of  the  arteries  during 
childhood  greatly  increase  their  efficiency  in  promoting  and  equalizing  the 
circulation,  and  also  minimize  the  ill  effects  on  the  circulation  which 
result  from  inflammatory  diseases  of  the  heart  and  strain  of  the  heart 
muscle   during  this  period  of  life. 

In  early  infancy  the  size  of  the  heart  and  the  capacity  of  the  arteries 
are  relatively  larger  than  at  any  other  period  and  the  capillary  circulation 
is  much  more  active.  The  relatively  large  size  of  the  great  blood  vessels, 
and  of  the  openings  through  which  they  enter  and  leave  the  heart,  is  of 
special  physiological  and  pathological  importance,  as  they  give  an  enor- 
mous advantage  to  the  infantile  heart  in  promoting  circulation.  The  in- 
fantile heart  acts  rapidly  (110  to  120  per  minute),  and  drives  a  com- 
paratively large  blood  stream,  with  little  resistance,  through  large  openings 
into  large  arteries  which,  by  reason  of  their  great  elasticity,  promote  the 
rapid  circulation  of  the  blood  so  characteristic  of  infancy.  These  condi- 
tions account  for  the  low  blood  pressure  (80  to  90  m.  m.).  As  the  child 
grows  older  the  heart  increases  in  size  and  strength,  but  there  is  little  or 
no  change  for  five  or  six  years  in  the  size  of  the  ostia,  and  thereafter  the 
increase  in  the  size  of  the  heart  continues  to  be  very  much  greater  than 
the  increase  in  size  of  the  ostia,  so  that  the  difference  between  the  capacity 
of  the  heart  and  the  capacity  of  the  arteries  gradually  increases  throughout 
childhood,  and  with  this  change  there  is  an  increase  in  blood  pressure 
reaching  110  mm.  at  ten  years  of  age.  The  total  body  weight  of  the 
adult  is  nineteen  times  that  of  the  newly-born  infant,  but  the  heart  is  only 
fifteen  times  as  heavy  as  at  birth,  so  that  the  relation  of  heart  weight 
to  body  weight  is  never  again  as  favorable  as  in  earliest  infancy.  (Hoch- 
singer.) 

483 


484  CONGENITAL  HEART   DISEASE 

The  younger  the  child  the  more  rapid  and  unstable  is  the  pulse.  Dur- 
ing the  first  year  the  normal  average  varies  from  100  to  140,  and  thereafter 
diminishes  four  or  five  beats  a  year,  until  at  ten  the  average  pulse  is 
about  80.  The  arrhythmia  so  frequently  observed  in  infancy  is  largely 
due  to  lack  of  inhibition,  which  results  in  an  instability  of  the  nervous 
mechanism  of  the  heart;  it  is  therefore  of  little  pathological  importance. 
Apart  from  the  normal  slight  irregularity  of  rhythm  of  the  infantile 
heart,  which  is  most  common  during  sleep,  it  is  very  easily  influenced 
in  its  rate  and  rhythm  by  pathological  conditions  of  all  kinds.  The  rapid, 
irregular  pulse,  which  is  produced  so  readily  from  slight  causes  in  infancy 
and  early  childhood,  is  not  of  such  pathological  significance  as  it  is  in 
later  childhood  and  adult  life.  This  is  especially  true  of  the  rapid  heart; 
the  normally  rapid  pulse  of  the  child  may  become  almost  uncountable 
from  slight  and  evanescent  causes. 

During  the  first  five  years  of  life  the  heart  increases  m  size,  strength, 
and  weight,  but  not  in  circumference  (Beneke).  From  this  time  to 
puberty,  while  its  openings  from  and  into  the  great  vessels  increase  very 
slowly  in  size,  there  is  much  greater  increase  in  the  size  of  the  heart,  and 
yet  it  does  not  keep  pace  in  development  with  the  chest  cavity.  The  long 
time  that  the  ostia  remain  almost  stationary  favors  the  muscular  power 
of  the  heart.  The  apex  beat  in  infancy  is  commonly  in  the  fourth  inter- 
costal space,  in  early  childhood  in  the  fifth  interspace,  and  in  later  child- 
hood slightly  lower.  In  infancy  it  may  be  just  outside  and  in  early  child- 
hood just  inside  the  mammary  line;  in  the  older  child  it  is  found  well 
within  this  line.  This  change  in  location  of  the  apex  is  due  not  alone  to 
the  growth  of  the  chest  cavity,  but  is  also  due  to  the  swinging  of  the 
heart  downward  and  inward  from  the  slightly  oblique  position  it  occupies 
in  infancy  to  its  perpendicular  position  in  childhood.  The  area  of  cardiac 
dullness,  while  it  actually  slowly  increases  with  the  growth  of  the  heart, 
gradually  continues  throughout  childhood  to  occupy  a  smaller  proportion 
of  the  chest  cavity,  and  the  external  border  of  this  dullness  is  thereby 
slowly  moved  from  just  without  to  within  the  mammary  line.  Its  outer 
border  in  infancy  is  slightly  outside  the  mammary  line,  its  inner  border 
the  midsternal  line,  its  lower  margin  the  fourth  or  fifth  interspace,  and 
its  upper  margin  the  second  interspace.  Enlargement  of  the  heart  is  deter- 
mined by  a  displacement  of  the  apex  beat  downward  or  outward,  and  by 
an  increase  in  the  width  of  the  cardiac  dullness  extending  either  2  or  3 
cm.  beyond  the  midsternal  or  the  mammary  lines. 


CHAPTER   LTV 
CONGENITAL    HEAET    DISEASE 

Etiology. — The  character  of  the  fetal  circulation  and  the  changes  which 
occur  in  it  at  birth  are  necessary  to  the  understanding  of  the  etiology  of 


SYMPTOMATOLOGY  485 

congenital  heart  disease.  The  most  important  peculiarities  of  the  fetal 
heart  are  the  direct  communication  between  the  two  auricles  through 
the  foramen  ovale,  and  the  large  size  of  the  Eustachian  valve  which  serves 
to  direct  the  blood  entering  the  right  auricle  from  the  inferior  vena  cava 
directly  through  the  foramen  ovale  into  the  right  auricle.  The  important 
peculiarity  in  the  arterial  system  of  the  fetus  having  a  bearing  on  con- 
genital heart  disease  is  the  communication  between  the  pulmonary  artery 
and  the  descending  aorta  by  means  of  the  ductus  arteriosus. 

At  birth  the  foramen  ovale  is  normally  closed  by  the  increased  pres- 
sure in  the  left  auricle  and  thereafter  there  should  be  no  direct  inter- 
change of  blood  between  the  auricles.  The  function  of  the  ductus  ar- 
teriosus should  also  cease  at  this  time  and  thereafter  there  should  be  no 
direct  communication  between  the  pulmonary  artery  and  the  descending 
aorta. 

Malformations,  due  to  arrested  or  perverted  development,  are  the 
most  common  causes  of  congenital  heart  disease.  They  are  frequently 
associated  with  the  persistence  of  the  above-named  fetal  conditions,  namely 
a  patulous  foramen  ovale  and  ductus  arteriosus,  and  they  are  also  com- 
monly associated  with  congenital  deformities  elsewhere  in  the  body,  show- 
ing that  they  are  due  to  the  same  general  causes,  producing  perverted  de- 
velopment in  various  parts  of  the  body.  Consanguinity  and  neurotic 
disease  in  the  parents,  and  early  psychic  influences  acting  on  the  pregnant 
mother,  may  be  etiologically  related  to  these  cases.  Heredity  may  also  be 
a  factor.  Fetal  endocarditis  is  also  an  important  cause  of  congenital  heart 
disease.  The  acute  infections,  rheumatism,  syphilis,  tuberculosis,  and 
traumatic  lesions  are  mentioned  as  possible  factors  of  this  condition. 

Symptomatology. — General  Symptoms. — Cyanosis,  which  is  one  of 
the  most  characteristic  symptoms,  is  due  to  a  venous  condition  of  the 
blood  and  not  to  passive  congestion  of  the  skin  from  weak  cardiac  action. 
In  aggravated  cases,  however,  the  cyanosis  is  increased  by  physical  ex- 
ertion and  the  superficial  veins  of  the  skin  may  gradually  become  more 
or  less  chronically  congested.  Cyanosis,  while  a  common  symptom,  does 
not  occur  in  all  forms  of  congenital  heart  disease.  It  is  nearly  always 
present  in  that  most  frequent  of  all  lesions,  congenital  stenosis  of  the 
pulmonary  artery,  and  always  occurs  in  a  very  pronounced  form  in  the 
rare  congenital  condition  where  the  aorta  takes  its  origin  from  the  right 
heart.  It  is  commonly  absent,  however,  in  lesions  of  the  ventricular  sep- 
tum and  in  open  ductus  arteriosus.  It  may  occur  during  the  first  days 
of  life,  or  it  may  not  appear  until  the  infant  is  two  or  three  years  of  age. 
The  earlier  and  deeper  the  cyanosis  the  graver  the  prognosis.  In  the 
less  severe  cases  cyanosis  may  come  and  go,  and  be  greatly  aggravated  by 
excitement  and  exertion. 

Bulging  of  the  precordia  is  an  early  and  frequent  symptom.  A  hori- 
zontal increase  of  precordial  dullness,  murmurs,  and  retinal  changes  may 
also  be  noted. 

Dyspnea,  which  is  a  marked  symptom  of  congenital  heart  disease,  is, 


486 


CONGENITAL   HEART   DISEASE 


as  a  rule,  in  direct  proportion  to  the  severity  of  the  cyanosis.  It  is  ag- 
gravated by  mental  excitement  and  physical  fatigue.  Clubbed  fingers  are 
found,  especially  in  those  cases  in  which  there  are  cyanosis  and  dyspnea. 
The  terminal  phalanges  are  knob-shaped  and  have  a  bluish  tinge.  The  toes 
may  also  show  this  same  deformity. 

The  blood  picture  associated  with  the  cyanosis  presents  the  following 
characteristics.  The  blood  has  a  dark  blue  color,  due  to  excess  of  CO2 
and  deficiency  of  0.  The  red  blood  corpuscles  are  increased  in  size 
(macrocythemia).  The  amount  of  hemoglobin  in  each  corpuscle  is  in- 
creased and  the  great  increase  in  the  percentage  of  hemoglobin  gives  to 
the  blood  a  very  high  specific  gravity,  sometimes  reaching  1,070.  The  most 
characteristic  blood  change,  however,  is  polycythemia;  the  number  of  red 

cells  may  reach  7,000,000,  or  even 
more.  This  increase  goes  hand  in 
hand  with  the  cyanosis,  a  high  red- 
cell  count  being  associated  with  the 
worst  cases  of  cyanosis.  The  above 
blood  changes  are  not  found  in  con- 
genital heart  diseases  unassociated 
with  cyanosis. 

The  malnutrition  and  defective 
development  will  be  in  direct  pro- 
portion to  the  physiological  incom- 
petency of  the  heart.  Curvature  of 
the  spine  and  other  rachitic  de- 
formities are  common. 

Enlargement  of  the  heart  from 
hypertrophy  or  dilatation  is  not  so 
marked  or  characteristic  in  the  com- 
mon forms  of  congenital  heart  dis- 
ease as  in  acquired  heart  lesions, 
but  when  it  does  occur  it  extends  to 
the  right  beyond  the  sternum.  In  some  of  the  rarer  congenital  conditions 
(patulous  ductus  arteriosus)  the  cardiac  hypertrophy  may  be  very  great. 

Systolic  murmurs  are  by  far  the  most  common.  They  may  be  diffused 
over  the  whole  cardiac  area,  but  they  are  commonly  heard  more  dis- 
tinctly at  the  base  of  the  heart;  diastolic  murmurs  are  very  rarely  con- 
genital. Hochsinger  says :  "Abnormally  loud  cardiac  murmurs  in  infants 
and  little  children  are  an  almost  infallible  sign  of  the  congenital  nature 
of  the  existing  heart  affection." 

Specific  Lesions. — The  differential  diagnosis  of  the  various  lesions 
occurring  in  congenital  heart  disease  is,  as  a  rule,  difficult  and  ofttimes 
impossible.  The  chief  reason  for  this  difficulty  lies  in  the  fact  that 
these  lesions  rarely  occur  singly;  in  nearly  all  instances  one  or  more 
congenital  defects  are  associated.  Of  the  various  lesions  of  congenital 
heart  disease  two  are  of  special  interest  to  the  clinician,  namely  stenosis 


Fig.  79. — Clubbing  of  the  Fingers  in  CoN' 

GENITAL    HeAET    DISEASE. 


SYMPTOMATOLOGY  487 

of  the  pulmonary  artery  and  congenital  defects  of  the  ventricular  septum. 
These  two  deformities  are  of  special  interest  because  they  make  uj)  the 
great  majority  of  the  cases  and  because  they  are  frequently  associated 
in  the  same  case.  In  addition  to  these,  the  following  deformities  occur: 
open  ductus  arteriosus,  open  foramen  ovale,  aortic  stenosis,  abnormalities 
in  the  origin  of  the  great  vessels  and  valvular  anomalies  involving  any 
of  the  valves  of  the  heart.  These  latter  anomalies,  however,  are  com- 
paratively rare,  and  when  they  occur  are  usually  associated  with  either 
pulmonic  stenosis  or  defects  in  either  the  ventricular  or  auricular  septum. 

Stenosis  of  the  Pulmonary  Artei'y. — Most  of  these  cases  are  due  to 
developmental  defects;  the  remainder  to  fetal  endocarditis.  This  is  the 
most  common  form  of  congenital  cardiac  defect;  68  per  cent,  are  due 
to  this  cause  (Peacock  and  Keith).  It  ranks  first  in  clinical  importance, 
because  of  its  rather  clear  symptom-complex  and  because  these  cases  may 
live  for  a  long  time  and  require  medical  supervision. 

Early  cyanosis,  associated  with  dyspnea,  clubbed  fingers,  and  the  char- 
acteristic blood  ])icture  previously  noted  under  General  Symptoms,  is  an 
important  part  of  the  symptom-complex  of  this  condition.  In  the  great 
majority  of  cases  there  is  a  loud,  rough,  long  systolic  murmur  heard  at 
the  base,  its  maximum  intensity  being  in  the  second  intercostal  space  just 
to  the  left  of  the  sternum ;  it  is  not  transmitted  to  the  arteries  of  the 
neck.  With  tiiis  murmur  a  distinct  thrill  may  be  felt  by  placing  the 
hand  over  the  cardiac  area;  the  absence  of  this  sign  may  depend  upon 
comjilicating  cardiac  defects.  The  heart  is  enlarged;  the  cardiac  dullness 
extends  to  the  right.  The  second  pulmonary  sound  is  not  accentuated  and 
may  be  absent.  The  above  signs  and  symptoms,  when  they  exist,  are  path- 
ognomonic of  pulmonary  stenosis,  and  in  the  great  majority  of  these  cases 
the  symjjtom  group  is  sufficiently  complete  to  make  the  diagnosis  clear. 
In  a  few  instances,  however,  either  by  reason  of  associated  defects  or 
from  inexplicable  causes,  this  symptom  group  is  so  modified  that  the  di- 
agnosis cannot  be  definitely  made. 

Prognosis. — Many  of  these  cases  live  to  adult  life.  Those  that  are 
complicated  with  severe  septum  defects  and  other  anomalies  die  early  from 
tuberculosis,  acute  endocarditis,  and  other  causes.  Deep  cyanosis,  and 
continuous  polycythemia  indicate  an  early  termination  of  the  disease. 

Defective  Interventricular  Septum. — This  is  one  of  the  most  common 
of  congenital  heart  lesions.  It  may  be  the  only  malformation,  but,  as  a 
rule,  it  is  associated  with  pulmonary  stenosis,  which  greatly  complicates 
the  symptom-com])lex.  It  is  also  usually  associated  with  an  open  foramen 
ovale,  which  condition,  however,  adds  little  to  the  symptom  group.  In  rare 
instances  the  entire  septum  may  be  absent,  but  partial  defects,  usually 
located  at  the  base,  make  up  the  majority  of  these  cases.  Of  the  various 
cardiac  anomalies  this  is  the  one  most  commonly  associated  with  de- 
formities in  other  parts  of  the  body. 

When  this  cardiac  defect  exists  as  an  independent  condition  it  is 
characterized  by  a  long,  harsh,  systolic  murmur  heard  over  the  whole  car- 


488  CONGENITAL   HEART    DISEASE 

diac  area,  having,  as  a  rule,  its  point  of  greatest  intensity,  according 
to  Roger,  in  the  upper  third  of  the  precordial  region.  It  is  not  heard 
over  the  great  vessels  of  the  neck,  but  is  transmitted  downward,  A  distinct 
cardiac  thrill  may  be  felt  in  many  of  these  cases  and  a  marked  systolic 
retraction  over  the  precordium  and  epigastrium  may  be  seen.  Cyanosis 
and  its  accompanying  symptoms  are,  as  a  rule,  absent;  when  present  they 
are  usually  slight  or  intermittent.  It  is  a  notable  fact  that  the  signs 
and  symptoms  of  this  condition  may  be  altogether  out  of  proportion  to 
the  extent  of  the  lesion.  In  some  instances  extensive  defects  in  the  inter- 
ventricular septum  exist  without  symptoms,  the  condition  being  discovered 
post  mortem.  In  other  instances  small  defects  give  rise  to  loud  murmurs. 
The  frequent  association  of  this  cardiac  anomaly  with  pulmonary  stenosis 
leads  to  a  confusion  of  the  two  symptom  groups.  In  such  instances  cyanosis 
and  its  accompanying  symptoms  are  an  important  part  of  the  combined 
symptom-complex.  Hochsinger  says  that  in  septum  defects  the  systolic 
murmur  is  associated  with  an  accentuation  of  the  second  sound  at  the 
pulmonary  area,  and  that  this  materially  assists  in  differentiating  these 
murmurs  from  those  produced  by  pulmonary  stenosis. 

Prognosis. — In  uncomplicated  cases  the  patients  may  live  to  adult  life ; 
the  majority  of  them  die  during  childhood. 

Persistent  Patulous  Ductus  Arteriosus  Botalli. — This,  as  a  clinical  en- 
tity, is  a  rare  condition,  but  occurs  more  frequently  in  association  with 
pulmonary  stenosis  and  defective  interventricular  septum.  Cyanosis  is,  as  a 
rule,  absent  in  these  cases,  and  the  skin  may  even  present  a  pallid  wax-like 
appearance.  The  dilated  pulmonary  artery  running  across  the  base  of 
the  heart  presents  a  ribbon-like  band  of  dullness  in  the  first  and  second 
intercostal  spaces  (Gerhardt).  In  Rontgen  ray  pictures  this  artery  pro- 
duces a  shadow  "like  a  cap"  covering  the  general  cardiac  shadow  (Arn- 
heim) ;  this  is  a  most  important  point  in  differential  diagnosis.  There 
is  a  loud,  long,  buzzing,  systolic  murmur  most  distinct  at  the  base  and 
transmitted  not  downward  but  into  the  carotids,  especially  the  left.  The 
second  pulmonary  sound  is  accentuated,  a  distinct  systolic  thrill  may  be 
felt,  and,  with  a  systolic,  a  diastolic  murmur  is  often  heard  following 
the  accentuated  second  pulmonic  sound.  Hypertrophy  of  the  right  and 
sometimes  of  the  left  ventricle  may  produce  a  great  increase  in  the  area 
of  cardiac  dullness,  and  the  systolic  pulsation  described  by  Gerhardt  may 
be  seen  in  the  second  left  interspace  where  the  heart  strikes  the  chest 
wall.  The  above  clinical  picture  is  greatly  complicated  when  the  patulous 
ductus  is  associated  with  pulmonary  stenosis,  as  the  blending  of  the  two 
syndromes  may  produce  a  symptom-complex  in  which  it  is  difficult  to 
make  out  with  clearness  either  condition. 

Treatment. — The  treatment  of  congenital  heart  disease  is  purely  symp- 
tomatic and  quite  unsatisfactory,  since  all  that  one  can  do  is  to  promote 
the  comfort  and  prolong  the  lives  of  these  children.  Attacks  of  cyanosis 
may  be  relieved  by  the  administration  of  oxygen.  During  the  first  days 
and  months  of  the  life  of  the  child  it  may  be  necessary  to  keep  up  the 


ETIOLOGY  489 

body  temperature  by  artificial  heat.  These  feeble  infants  are  especially 
prone  to  gastrointestinal  disturbances  and  must  therefore  be  fed  with 
great  care;  breast-milk  is  ofttimes  the  only  food  upon  which  they  can 
thrive.  If  the  child  lives,  care  must  be  exercised  to  prevent  the  development 
of  spinal  curvature  which  frequently  occurs.  As  children  of  this  type 
always  remain  weak  and  undeveloped  they  must  throughout  their  lives 
be  carefully  protected  from  contagious  diseases. 

Congenital   heart   lesions   require    digitalis   only   when   the    symptoms 
of  myocardial  insufficiency  are  very  marked. 


CHAPTER    LV 

ACUTE     ENDOCAEDITIS 

Acute  endocarditis  is  an  inflammation  of  the  endocardium,  most  marked 
on  and  near  the  valves.  In  children  especially  the  whole  heart  muscle  is 
more  or  less  involved.  It  is  essentially  an  infection,  but  the  disease  varies 
greatly  in  severity  from  the  simple  cases  which  run  a  benign  course  of 
two  or  three  weeks'  duration  to  the  septic  or  so-called  ulcerative  cases, 
which,  with  few  exceptions,  terminate  fatally.  The  severity  of  these  cases 
depends  partly  upon  the  susceptibility  of  the  individual,  but  more  on  the 
character  of  the  microorganism  which  is  producing  the  inflammation.  In 
fetal  life  the  right  side  of  the  heart  is  usually  affected.  After  birth  the 
left  is  chiefly  involved. 

Etiology. — It  is  extremely  rare  in  infancy,  uncommon  before  the  fourth 
year,  and  thereafter  increases  in  frequency  until  the  tenth  year;  between 
this  age  and  the  fifteenth  year  of  life  it  is  most  commonly  seen.  It  is 
observed  most  frequently  in  the  late  winter  and  spring.  Heredity  is  an 
important  predisposing  factor. 

Rheumatism  is  the  great  exciting  cause.  Rheumatic  arthritis  or  chorea 
is  associated  with  endocarditis  in  70  to  80  per  cent,  of  the  cases;  in  order 
to  understand  this  relationship,  it  should  be  remembered  that  rheumatism 
is  a  general  febrile  disease  of  infective  origin,  whose  chief  manifestations, 
as  Cheadle  has  taught,  are  non-suppurative  polyarthritis,  acute  inflam- 
matory diseases  of  the  heart,  and  chorea.  One  or  all  of  these  manifesta- 
tions may  be  present  at  the  same  time,  or  any  one  may  take  precedence 
in  the  order  of  their  development,  but  most  commonly  the  arthritis  pre- 
cedes the  heart  disease  and  the  chorea.  Polyarthritis  and  chorea  are  there- 
fore rheumatic  syndromes,  commonly  associated  with  endocarditis,  and  their 
presence  should  make  the  physician  ever  watchful  for  the  development 
of  heart  symptoms,  marking  the  insidious  onset  of  inflammatory  disease 
of  this  organ.  On  the  other  hand,  in  searching  for  evidence  of  rheumatism 
to  explain  an  existing  endocarditis,  the  physician  should  keep  in  mind  the 
mild  character  of  the  rheumatic  polyarthritis  that  occurs  in  childhood.  In 
many  instances  there  will  be  a  history  of  a  mild  febrile  attack,  with  per- 


490  ACUTE  ENDOCAEDITIS 

Imps  slight  indefinite  pains,  and  joint  tenderness  so  mild  as  to  be  dis- 
covered only  on  pressure. 

The  lymphoid  ring  of  the  pharynx  is  the  common  portal  of  entrance 
for  bacteria  (Jacobi),  and  Packard  has  called  attention  to  the  fact  that 
endocarditis  in  children  is  very  commonly  preceded  by  tonsillitis.  Influ- 
enza, scarlet  fever,  tuberculosis,  pneumonia,  and  septic  processes  in  gen- 
eral may  be  complicated  or  followed  by  an  endocarditis. 

Pathology.  — The  pathological  anatomy  of  endocarditis  in  childhood  is 
very  similar  to  that  which  occurs  in  the  adult.  The  different  forms  of 
this  disease  have  not  been  definitely  associated  with  specific  microorganisms ; 
streptococci  and  staphylococci  are  most  commonly  found;  the  pneumo- 
coccus,  gonococcus,  typhoid  bacillus,  and  other  microorganisms  are  more 
rarely  observed.  The  valves  are  the  sites  of  the  most  marked  lesions,  the 
mitral  being  by  far  the  most  commonly  affected.  The  endocardium  is  thick- 
ened, its  superficial  epithelium  is  destroyed,  and  fibrous  vegetations  occur, 
which  thicken  and  prevent  the  proper  closing  of  the  valves.  Small  par- 
ticles may  be  separated  from  these  vegetations  and  carried  by  the  blood 
to  distant  organs,  producing  infarcts  and  secondary  infections.  As  the 
inflammation  subsides  these  fibrous  deposits  may  be  in  great  part  ab- 
sorbed, but  resulting  contractions  of  the  cordae  tendinae  or  deformities  of 
the  valves  themselves  commonly  result  in  their  incomplete  closure  with 
a  resultant  incompetency  or  leakage  of  the  valve.  In  the  ulcerative  form 
the  vegetations  are  broken  down  by  ulcerative  processes  and  septic  par- 
ticles are  cast  into  the  blood  stream,  thus  producing  a  general  septicopy- 
emia with  localized  abscesses  in  various  organs  of  the  body. 

Symptomatology. — An  insidious  onset  is  characteristic  of  endocarditis 
in  childhood.  This  disease  usually  develops  with  few  or  no  symptoms 
directing  attention  to  the  heart  itself.  Fever  is  present,  but  the  irregular 
temperature  curve  is  usually  mistaken  for  an  exacerbation  of  the  fever  of 
the  rheumatism  or  other  acute  infection  with  which  the  endocarditis  is 
commonly  associated.  Broadbent  says  that  an  intermittent  or  irregular 
fever  in  childhood,  which  resists  quinin,  often  indicates  endocarditis. 
Epistaxis  may  occur.  Shortness  of  breath,  rapid  and  irregular  action  of 
the  heart,  with  slight  precordial  distress,  may  be  present  in  some  cases; 
this  is  especially  true  where  the  myocardium  is  involved  and  cardiac  dila- 
tation is  the  first  evidence  of  endocarditis.  In  other  instances  progressive 
wasting  and  anemia,  unaccompanied  by  acute  symptoms,  may  call  for  a 
careful  physical  examination,  which  reveals  the  cardiac  bruit  of  endocar- 
ditis. The  insidious  onset  of  this  condition,  therefore,  calls  upon  the 
physician  to  make  a  careful  physical  examination  of  the  heart  daily  in 
all  cases  of  rheumatism  and  other  infections  which  may  be  etiologically 
related  to  endocarditis. 

The  most  important  clinical  sign  of  this  disease  is  a  Joiv,  blowing 
systolic  bruit,  heard  most  distinctly  at  the  apex,  and  transmitted  toward 
the  axillary  region;  this  murmur  means  mitral  regurgitation.  As  the 
mitral  valve  is  almost  exclusively  affected  in  this  disease  the  heart  murmur 


SEPTIC    ENDOCARDITIS  491 

has  its  point  of  greatest  intensity  almost  always  at  the  apex.  In  a  small 
minority  of  these  cases  there  is  a  mitral  stenosis,  which  produces  a  pre- 
systolic apical  bruit,  usually  associated  with,  but  rarely  independent  of, 
the  systolic  apical  bruit.  Both  systolic  and  diastolic  apical  bruits  may 
exist  for  a  considerable  length  of  time  without  producing  reduplication 
of  the  second  sound  over  the  pulmonary  valve.  Aortic  disease  is  infrequent 
in  the  acute  endocarditis  of  children.  In  this  condition  systolic  murmurs 
are  the  more  common,  and  have  their  point  of  greatest  intensity  in  the 
second  intercostal  space  to  the  right  of  the  sternum;  they  are  due  to  the 
roughness  of  the  aortic  valves  and  ostium.  In  rare  instances  diastolic 
aortic  murmurs  may  be  hoard  in  the  same  location.  Percussion  is  of  little 
value,  since  there  is  little  increase  in  the  size  of  the  heart  during  an  acute 
attack,  except  in  cases  of  acute  dilatation,  and  here  the  symptoms  of 
cardiac  distress  are  so  marked  that  the  nature  of  the  lesion  can  scarcely  be 
overlooked. 

Septic  Endocarditis. — Septic  endocarditis  is  a  term  now  in  general  use 
to  describe  those  cases  of  endocarditis  which  are  complicated  by  a  general 
septicopyemia.  They  do  not  represent  a  separate  or  distinct  disease,  but 
are  produced  by  the  same  microorganisms  sometimes  found  in  simple 
endocarditis.  In  simple  endocarditis  these  microorganisms  confine  their- 
ravages  almost  exclusively  to  the  heart;  occasionally  they  are  transmitted 
through  the  blood  stream  to  distant  parts  of  the  body,  where  they  may 
produce  inflammatory  infarcts.  In  the  septic  form,  however,  there  is  a 
bacteriemia  of  the  same  microorganisms  which  have  produced  the  en- 
docarditis. The  focus  for  the  distribution  of  this  general  infection  is  in 
the  ulcerated  heart  valves,  from  which  the  septic  microorganisms  are 
thrown  into  the  blood  stream  and  are  generally  distributed  throughout 
the  body,  producing  septic  foci  in  distant  organs;  in  this  way  the  general 
clinical  picture  of  septicopyemia  is  added  to  that  of  the  existing  en- 
docarditis. These  cases  are  not  necessarily  septic  or  ulcerative  from  the 
start.  Some  years  ago  I  reported  three  fatal  cases  of  septic  endocarditis, 
following  ulcerative  tonsillitis.  In  each  instance  the  patient  recovered 
from  the  first  attack  of  endocarditis  with  damaged  mitral  valves,  and 
months  later  secondary  attacks  of  ulcerative  tonsillitis  were  followed  by 
endocarditis,  which  assumed  the  septic  or  ulcerative  type  and  ended  fa- 
tally. In  one  of  these  cases  the  necropsy  showed  ulceration  of  the  mitral 
valve  on  both  leaflets. 

The  term  malignant,  used  to  describe  these  cases,  is  a  misnomer,  which 
has  added  confusion  to  this  subject,  as  they  are  not  malignant  nor  are 
they  necessarily  hopeless.  Adams  reports  three  recoveries  in  forty-seven 
cases  collected  from  the  literature  (one  of  these  was  his  own  case),  and 
the  probabilities  are  that  these  figures  do  not  represent  the  full  percentage 
of  recoveries.  The  important  point  to  bear  in  mind  is  that  the  majority 
of  these  cases  are  not  septic  in  the  first  attack  and  that  subsequent  at- 
tacks are  produced  by  a  secondary  invasion  from  the  same  microorganisms 
which  produced  the  first  attack,  but  which,  in  the  meantime,  have  been 


492  ACUTE  ENDOCARDITIS 

held  quiescent  in  foci  commonly  located  in  the  tonsils,  but  sometimes  in 
the  lungs,  pelvis,  and  subcutaneous  tissues.  In  any  one  of  these  attacks 
an  ulceratiTC  endocarditis  may  develop  which  may  result  in  a  general  sep- 
ticopyemia. 

Symptomatology. — The  symptoms  of  septic  endocarditis  are  those  of 
severe  endocarditis  plus  a  general  septicopyema.  One  of  the  most  im- 
portant diagnostic  signs  is  the  finding  of  septic  organisms  in  the  blood. 
These  cases  are  characterized  by  high  and  variable  temperatures,  such  as 
are  seen  in  sepsis,  the  temperature  commonly  approaching  or  falling  be- 
low the  normal  and  rising  to  104°,  105°,  or  106°  F.  within  the  next 
twelve  hours.  There  are  great  prostration,  delirium,  chilly  sensations, .and 
the  body  is  frequently  covered  with  a  petechial  rash.  A  high  leukocyte 
count  is  present.  These  cases  usually  end  fatally,  but,  under  modern 
methods  of  treatment,  the  death  rate  promises  to  be  less  than  it  has 
formerly  been. 

Diagnosis. — Accidental  murmurs  due  to  anemia,  cardiac  neuroses,  and 
other  causes  may  occur  and  are  to  be  differentiated  from  the  bruits  pro- 
duced by  endocarditis.  The  above-mentioned  murmurs  are  commonly 
heard  most  distinctly  at  the  base,  are  not  transmitted  to  the  axillary  re- 
gion, and  occur  in  non-febrile  conditions.  A  relative  insufficiency  of  the 
mitral  valve  may  be  caused  by  cardiac  dilatation;  the  murmur  thus  pro- 
duced is  associated  with  enlargement  of  the  heart  and  displacement  of 
the  apex  beat,  and  appears,  as  a  rule,  rather  suddenly  under  conditions 
producing  heart  strain.  The  pericardial  friction  murmur  rarely  causes 
confusion;  it  is  not  transmitted,  is  intermittent  in  character,  and  its 
point  of  intensity  is  usually  located  at  the  base. 

Prognosis. — The  prognosis  in  acute  simple  endocarditis,  so  far  as  life 
is  concerned,  is  good.  The  great  majority  of  these  cases  recover  in  three 
or  four  weeks.  In  a  small  minority  there  is  complete  recovery,  but  in 
the  great  majority  of  instances  incompetency  of  the  mitral  valve  occurs, 
which  results  in  a  leakage  at  the  valve  and  a  crippling  of  the  heart,  which 
is  compensated  for  by  cardiac  hypertrophy.  Secondary  attacks  of  en- 
docarditis may  result  in  further  crippling  of  the  heart  and  in  the  pro- 
duction of  chronic  valvular  disease.  In  rare  instances  an  ulcerative  en- 
docarditis develops,  associated  with  a  septicopyemia ;  the  prognosis  in 
these  cases  is  very  bad,  the  great  majority  of  them  terminating  fatally. 

Prophylaxis. — This  comprehends  the  careful  treatment  of  rheumatism 
and  of  all  the  acute  infections.  According  to  Forchheimer,  the  alkaline 
treatment  of  rheumatism  diminishes  the  tendency  to  fibrin  formation  and 
thereby  to  endocarditis.  In  all  of  the  acute  infections,  especially  rheuma- 
tism, the  heart  must  be  carefully  watched  and  the  patient  confined  to  bed 
during  the  acute  stages  of  these  diseases,  and,  in  the  event  that  syrAptoms 
develop  referable  to  the  heart,  a  longer  period  of  absolute  rest  in  bed 
must  be  insisted  upon.  The  most  important  prophylactic  treatment,  how- 
ever, consists  in  the  prevention  of  second  and  third  attacks  of  endocarditis. 
If  the  primary  attack  was  associated  with  chorea,  rheumatic  arthritis,  or 


TREATMENT  493 

other  symptoms  indicating  the  rheumatic  origin  of  the  disease,  then  the 
subsequent  life  of  the  patient,  at  least  for  a  number  of  years,  should  be 
carefully  regulated  to  prevent  second  attacks  of  rheumatism,  and  he  should 
take  at  intervals,  especially  during  the  winter  months,  courses  of  medical 
treatment  which  include  the  alkalies  and  salicylates.  These  medicines 
materially  assist  in  warding  off  the  second  and  third  attacks.  These  pa- 
tients should  spend  their  winters  for  a  number  of  years  in  mild  climates; 
where  this  is  impossible  they  should  be  protected  by  woolen  underclothing 
and  proper  footwear  from  the  cold,  damp  weather  of  the  winter  months. 
But  the  most  important  prophylactic  measures  in  these  cases  are  the  re- 
moval of  diseased  tonsils  and  adenoids,  and  the  daily  disinfection  of  the 
throat  and  nose  during  the  winter  months  with  mild  alkaline  antiseptics. 
As  previously  noted,  the  lymphoid  ring  of  the  pharynx,  which  includes  the 
tonsils  and  adenoids,  is  not  only  the  common  portal  of  entrance  for  the 
germs  which  produce  endocarditis,  but  they  offer  a  hiding  place  for  them 
in  the  intervals  between  the  attacks,  which  makes  it  possible  for  slight 
causes,  such  as  exposure  to  damp  cold,  to  set  up  a  tonsillitis,  to  be  followed 
by  another  attack  of  endocarditis.  It  is  my  belief  that  if  the  tonsils  and 
adenoids  in  all  these  cases  were  removed  following  the  first  attack  of 
endocarditis,  and  thereafter  during  the  winter  months  the  throat  was  daily 
douched  Avith  an  alkaline  antiseptic,  relapsing  endocarditis  would  be 
less  common,  and  septic  endocarditis  could,  in  most  instances,  be  pre- 
vented. 

Treatment. — The  all-important  part  of  the  treatment  is  prolonged  rest 
in  bed,  and  unless  this  is  carried  out  satisfactorily  other  curative  measures 
are  without  avail.  This  implies  that  the  child  must  be  kept  as  quiet  as 
possible,  not  allowed  to  sit  up,  and  not  permitted  to  get  out  of  bed  for 
any  purpose  whatever.  The  younger  the  child  the  more  difficult  it  is  to 
carry  this  out  in  a  satisfactory  manner.  During  the  early  acute  inflam- 
matory stage  an  ice-bag  or  coils  of  cool  running  water  should  be  applied 
over .  the  heart ;  this  is  especially  indicated  when  precordial  pain  and 
rapid  heart  action  are  present.  In  the  less  severe  cases  this  application 
should  be  made  at  intervals  during  the  day  and  under  no  conditions  should 
it  be  used  when  it  interferes  with  normal  sleep,  as  sleep  is  almost,  if  not 
quite,  as  important  as  rest  in  bed.  The  surroundings  should  be  as  quiet 
as  possible  so  as  to  avoid  mental  stimulation  and  nervous  excitement.  If 
the  child  be  restless,  nervous,  and  sleepless  the  bromides  are  indicated, 
and  occasionally  opiates  may  be  necessary  to  secure  proper  rest;  where 
these  are  indicated,  a  hypodermic  injection  of  1/20  to  1/50  of  a  grain  of 
morphin  may  be  given  at  bedtime.  All  sedative  medication,  however, 
should  be  discontinued  as  soon  as  possible  and  should  be  given  only  in 
those  cases  where  the  nervous  irritation  is  markedly  interfering  with  the 
rest  of  the  child.  The  diet  should  be  carefully  selected  to  suit  the  wants 
of  the  individual  child;  milk,  cereals,  and  eggs  may  form  the  basis  of 
this  diet  during  the  acute  stage.  The  bowels  should  be  kept  open  by  mild 
cathartic  medication.     If  rheumatism  be  present,  the  salicylates  should 


494    MYOCARDITIS  AND   ACUTP]   CAEDTAC   DILATATION 

be  given  until  these  symptoms  are  under  control;  aspirin,  salol,  and  winter- 
green  sodium  salicylate  may  bo  used,  as  recommended  in  the  chapter  on 
Rheumatism.  When  other  internal  medication  is  not  indicated,  bicarbonate 
of  soda  or  some  other  alkali  may  be  the  routine  treatment ;  in  older  children 
two  or  three  drops  of  tincture  of  nux  vomica  may  be  given  with  each  dose 
of  the  alkali.  In  the  treatment  it  should  be  remembered  that  all  medicines 
that  upset  the  stomach  or  interfere  with  the  appetite  do  more  harm  than 
good.  Where  the  heart  is  weak  and  the  pulse  irregular  tincture  of  digitalis 
or  strophanthus  may  be  used  in  from  3  to  5-drop  doses.  In  most  eases 
of  primary  simple  acute  endocarditis  cardiac  stimulants,  however,  are  not 
only  unnecessary  but  are  usually  contraindicatcd. 

The  important  question  to  decide  in  every  case  is  the  length  of  time 
the  patient  should  remain  in  bed;  even  in  the  mild  cases  one  month  is 
the  minimum  time.  When  the  physician  has  decided  that  the  patient 
has  recovered  sufficiently  he  may  test  the  action  of  the  heart  by  allowing 
him  to  sit  up  in  bed,  and,  if  no  ill  effects  follow,  within  a  few  days  he 
may  be  placed  in  a  chair  for  a  few  hours  during  the  day,  and  later  may 
be  allowed  to  walk  across  the  room.  In  this  way  the  patient,  during  con- 
valescence, should  be  carefully  guarded  against  overexertion  until  the 
heart  is  able  to  do  the  work  ordinarily  required  of  it.  If  the  patient  be 
guided  in  this  way  to  a  satisfactory  recovery,  and  future  attacks  of  en- 
docarditis be  prevented,  the  heart,  in  most  instances,  even  though  a  loud 
mitral  murmur  persists,  acquires  a  physiological  competency  which  will 
enable  the  individual,  throughout  a  long  life,  to  follow  many  of  the 
wage-earning  vocations. 

Ulcerative  Endocarditis. — This  is  the  same  as  that  of  ordinary  en- 
docarditis plus  the  treatment  for  septicopyemia.  The  antistreptococcic 
serum,  and  collargolum  in  the  form  of  unguentum  Crede  should  be  used 
as  outlined  in  the  chapter  on  Scarlet  Fever.  A  few  cases  have  recovered 
under  the  use  of  these  remedies,  and,  as  they  can  do  no  harm,  they  should 
be  given  in  every  case.  The  treatment  by  homologous  vaccines  offers  a 
chance  for  recovery,  especially  in  the  so-called  Schottmueller's  disease. 
From  blood  cultures  the  microorganism  causing  the  trouble  is  isolated,  and 
from  this  organism  vaccines  are  made  according  to  Wright's  method.  If 
these  vaccines  be  administered  early  in  the  course  of  the  disease  good 
results  may  be  hoped  for  in  some  cases. 


CHAPTER  LVI 
MYOCAEDITIS     AND     ACUTE     CARDIAC     DILATATION 

MYOCARDITIS 

Myocarditis  is  very  common  in  childhood.  It  is  usually  produced  by 
bacterial  toxins  and  is  therefore  a  common  complication  of  the  acute  in- 
fections, especially  diphtheria,  scarlet  fever,  influenza,  pneumonia,  typhoid 


MYOCARDITIS  495 

fever,  and  whooping-cough.  The  toxins  act  directly  upon  the  cardiac 
nerves  and  muscles,  producing  parenchymatous  degenerations.  The  mus- 
cular fibers  may  show  granular,  hyalin  and  fatty  degeneration,  and  under 
this  change  the  heart  muscle  becomes  weak,  flaccid,  and  readily  undergoes 
dilatation. 

Myocarditis  may  also  be  produced  by  the  bacterial  invasion  of  the 
organ  along  the  line  of  the  blood  vessels  and  connective  tissue ;  in  this  form 
true  inflammatory  changes,  involving  especially  the  interstitial  tissue,  are 
produced.  The  most  common  offending  organisms  are  streptococci, 
staphylococci  and  pneumococci,  and  the  heart  muscle  itself  may  be  in- 
filtrated with  pus  cells  and  may  be  the  site  of  small  abscesses.  These  cases 
commonly  result  from  septic  emboli  carried  to  the  heart,  and  may  occur 
therefore  as  a  complication  of  scarlet  fever,  diphtheria,  ulcerative  ton- 
sillitis, septicopyemia,  osteomyelitis,  and  other  diseases  characterized  by 
sepsis.  In  other  cases  the  myocarditis  may  occur  as  a  complication  of 
endocarditis  and  pericarditis;  in  many  of  these  rheumatism  is  the  exciting 
cause. 

Symptomatology. — The  parenchymatous  form  of  myocarditis,  due  to 
bacterial  toxins,  is  of  special  interest  to  the  physician  because  it  is  the 
most  common  form  and  the  one  in  which  his  skill  can  be  of  the  most 
value.  Symptoms  of  parenchymatous  myocarditis  may  develop  at  any 
time  throughout  the  course  of  the  above-named  infections,  but  they  occur 
more  commonly  during  the  stage  of  convalescence.  An  intermittent  pulse 
and  irregularity  in  the  cardiac  rhythm  may  be  the  first  symptoms  announc- 
ing the  onset  of  myocarditis,  and  they  are  especially  significant  when 
they  occur  in  diphtheria,  scarlet  fever,  pneumonia,  and  severe  forms  of 
influenza.  As  the  disease  progresses  apical  systolic  murmurs  appear,  the 
pulse  becomes  rapid,  flickering  and  irregular,  and  the  apex  beat  may  be 
feeble  and  difficult  to  locate.  As  cardiac  dilatation  develops,  the  heart 
sounds  may  be  indistinct,  and  other  and  more  complicated  cardiac  mur- 
murs may  occur,  and  the  patient  commonly  complains  of  pain  in  the 
precordial  region  and  suffers  from  nervous  unrest.  Pallor,  cold  extrem- 
ities, dyspnea,  and  cyanosis  may  be  present.  In  diphtheria  the  above  symp- 
toms, when  associated  with  syncope  and  vomiting,  are  especially  ominous 
and  not  infrequently  presage  death  from  myocardial  insufficiency.  In 
the  milder  cases,  however,  a  modification  of  the  above  symptom  group  may 
continue  for  days  or  weeks  until  final  recovery  is  established.  The  ir- 
regular and  intermittent  pulse  sometimes  continues  for  months  or  is 
readily  developed  on  slight  muscular  exercise. 

Interstitial  myocarditis  presents  the  same  symptom  group  as  that 
above  outlined  for  the  parenchymatous  form.  The  diagnosis  therefore  of 
this  condition  can  only  be  inferred  from  the  fact  that  it  is  preceded  by 
or  associated  with  endocarditis,  pericarditis,  or  septic  processes.  In  these 
latter  cases  a  septic  type  of  temperature  is  generally  present. 

Prognosis. — The  prognosis  in  the  parenchymatous  form  is,  as  a  rule, 
good  and  recovery,  when  it  occurs,  is  usually  complete.     In  the  inter- 
83 


496     MYOCARDITIS   AXU   ACUTE    CARDIAC    DILATATION 

stitial  form  tlie  prognosis  is  bad.  Most  of  the  cases  die,  and  in  those  that 
survive  recovery  is,  as  a  rule,  inco^^iplete.  the  heart  muscle  being  per- 
manently injured  and  frequently  embarrassed  by  a  coexisting  endocardi- 
tis or  pericarditis. 

ACUTE    CARDIAC   DILATATION 

Acute  cardiac  dilatation  is  commonly  the  result  of  a  preceding  myo- 
carditis, but,  on  the  other  hand,  when  it  does  occur  as  a  primary  condition 
it  is  almost  always  followed  by  more  or  less  myocarditis.  The  two  con- 
ditions are  therefore  inseparably  associated  in  the  medical  mind,  but,  not- 
withstanding this,  acute  cardiac  dilatation  deserves  separate  consideration. 

Etiology. — Influenza  and  whooping-cough  may  cause  this  condition  in 
infants  and  in  young  and  delicate  children.  The  dilatation  of  the  heart 
in  whooping-cough  is  largely  produced  by  the  strain  on  the  cardiac  muscle, 
which  results  from  an  overful  heart  attempting  to  force  l)lood  through 
the  cardiac  ostia  under  the  greatly  increased  resistance  which  occurs  dur- 
ing an  acute  paroxysm  of  this  disease.  I  also  believe  with  Forchheimer 
that  the  violent  paroxysmal  fits  of  coughing,  ofttimes  seen  in  influenza, 
may  produce  cardiac  dilatation.  The  toxins  of  influenza  may  also  weaken 
the  heart  muscle  and  thus  predispose  to  dilatation.  Acute  dilatation  may 
result  in  rapidly  growing  malnourished  children,  especially  during  the 
pubertic  period,  from  the  severe  strain  thrown  upon  the  heart  by  bicycle 
riding,  foot-racing,  jumping-the-rope,  and  other  forms  of  violent  ex- 
ercise. It  is  most  commonly  seen,  however,  as  a  condition  secondary  to 
acute  myocarditis,  and  is  especially  to  be  feared  and  watched  for  in  the 
parenchymatous  form  of  this  disease,  which  is  produced  by  the  toxins 
of  the  acute  infections.  It  also  occurs  with  the  failing  compensation  of 
chronic  valvular  disease  and  may  occur  as  one  of  the  earlier  symptom 
groups  of  acute  endocarditis. 

Frogfnosis. — The  prognosis  depends  largely  upon  the  cause;  where 
mechanical  conditions  are  wholly  or  in  great  part  responsible  for  the  dila- 
tation recovery  is,  as  a  rule,  rapid  and  complete.  When  acute  toxic  myo- 
carditis is  the  cause  the  prognosis  is  grave,  but  many  of  these  cases  end 
in  complete  recovery.  ^Hien  occurring  as  a  symptom  group  of  acute  en- 
docarditis the  prognosis,  so  far  as  the  symptoms  of  dilatation  are  con- 
cerned, is  on  the  whole  favorable.  When  occurring  as  a  symptom  of 
failing  compensation  in  chronic  valvular  disease  the  prognosis  is  grave, 
yet  many  of  these  cases  have  repeated  attacks  of  acute  dilatation  from 
which  they  at  least  partially  recover. 

Diagnosis. — The  diagnosis  of  this  condition  must  be  made  in  connec- 
tion with  the  etiological  factors  which  produce  it.  The  physical  signs  in 
every  instance  are  the  same,  but  the  general  symptoms  vary  materially 
with  the  cause  which  has  been  operative  in  producing  the  dilatation.  A 
rapid  increase  in  the  area  of  cardiac  dullness  with  a  marked  displacement  of 
the  apex  beat  downwardly  and  outwardly  always  occurs.    The  cardiac  dull- 


PROPHYLAXIS    AXD    TREATMEXT  497 

ness  ma}'^  extend  from  outside  the  mammary  line  to  the  right  of  the 
sternum,  and  the  apex,  which  is  feeble  and  diffused,  may  be  felt  in  the 
fifth  or  sixth  interspace  well  outside  the  mammary  line.  A  soft  systolic 
murmur  may  sometimes  be  heard  at  the  apex,  and  the  second  sound  over 
the  pulmonary  area  may  be  accentuated.  This  acute  enlargement  of  the 
heart,  made  out  by  physical  signs,  occurring  with  any  of  the  conditions 
above  noted  as  being  associated  with  the  etiology  of  acute  dilatation,  may 
be  accepted  as  proof  of  the  existence  of  this  condition. 

Acute  dilatation  is  not  always  manifested  by  the  same  symptom  group. 
Its  presence,  however,  may  be  suspected  when  etiological  conditions  fa- 
vorable to  its  development  are  followed  by  sudden  syncope,  rapid  breath- 
ing (tachypnea)  and  rapid  and  irregular  heart  action.  In  infants  espe- 
cially a  tendency  to  somnolence  follows  this  acute  prostration.  From 
these  alarming  symptoms  the  child  may  gradually  recover  and  present 
for  a  time  the  milder  symptoms  of  cardiac  distress  above  outlined  under 
Acute  Myocarditis.  Repeated  attacks  of  this  kind  may  occur,  somewhat 
milder  in  character,  as  the  disease  progresses  to  a  favorable  termination, 
or  death  may  result  at  any  time  from  complete  myocardial  insufficiency. 
In  older  children  cardiac  dilatation  may  produce  a  symptom  group  closely 
resembling  angina  pectoris.  These  cases,  when  associated  with  acute  or 
chronic  endocarditis,  may  present  the  clinical  picture  of  angina  sine  dolore 
described  by  Musser,  the  absence  of  pain  being  due  to  the  relief  which  the 
mitral  insufficiency  gives  to  the  interventricular  tension.  In  one  such 
patient,  nine  years  of  age,  whom  I  observed,  the  respirations  reached  97 
per  minute,  were  shallow  in  character,  and  not  accompanied  by  cyanosis. 
During  an  attack  she  sat  up  in  bed  with  body  rigid,  shoulders  elevated,  and 
head  thrown  back.  Her  eyes  were  fixed  and  staring;  there  was  an  ex- 
pression of  fear  and  anxiety  on  her  face,  but  when  asked  if  she  had  pain 
she  answered  "no."  The  symptoms  in  this  case  were  associated  with  an 
acute  mitral  insufficiency  due  to  endocarditis.  The  angina  symptoms  were 
readily  controlled  by  nitroglycerin  and  the  patient  made  a  satisfactory 
recovery,  leaving  the  hospital  with  full  compensation  for  a  well-marked 
mitral  insufficiency. 


PROPHYLAXIS  AND  TREATMENT 

Prophylaxis. — Rapidly  growing  anemic  children  should  not  be  permitted 
to  engage  in  forms  of  physical  exercise  which  will  overstrain  the  heart. 
This  is  especially  important  in  children  suffering  from  functional  dis- 
turbances of  this  organ.  In  whooping-cough  all  violent  exercise  should 
be  prohibited,  and  in  those  cases  where  the  paroxysms  are  very  severe 
and  are  associated  with  marked  disturbance  of  the  heart  action  it  may 
be  necessary  to  confine  them  to  bed  for  a  number  of  weeks  until  the  dan- 
gers of  acute  dilatation  and  myocarditis  are  passed.  In  diphtheria,  pneu- 
monia, and  influenza  it  is  of  the  greatest  importance  that  the  heart  should 


498  CHKOXIC   VALVULAR    DISEASE 

he  carefully  watched,  so  that  with  the  first  symptoms  of  cardiac  distress 
the  patient  may  be  treated  for  myocarditis. 

Treatment. — This  is  much  the  same  as  in  acute  endocarditis.  Absolute 
and  prolonged  rest  should  be  insisted  upon.  The  patient  should  not  only 
be  confined  to  bed  but  he  should  not  be  allowed  to  do  anything  for  himself 
that  can  be  done  by  others;  a  fatal  issue  in  many  cases  has  been  precipitated 
by  the  effort  of  sitting  up  in  bed.  During  early  convalescence  great  care 
must  be  used  in  determining  the  amount  of  exercise  the  patient  may  take 
with  safety.  An  icebag  over  the  precordial  region  is  indicated  if  there 
be  cardiac  pain  and  rapid  heart  action.  Caffoin  sodium  benzoate  or 
salicylate  (I/2  to  2  grains),  digitalis  (2  to  5  drops  of  the  tincture),  or 
str3^chnin  (1/100  to  1/200  of  a  grain)  may  be  given,  as  indicated,  at 
intervals  of  three  or  four  hours.  Camphor,  dissolved  in  sterile  oil,  may  be 
given  hypodermically.  In  most  cases  one  depends  almost  entirely  upon 
the  cautious  use  of  tincture  of  digitalis  or  tincture  of  strophanthus ;  these 
drugs  may  be  given  at  four  to  six-hour  intervals  and  in  2  to  5-minim  doses, 
according  to  the  age  of  the  child.  If  the  action  of  the  heart  is  improved 
under  their  administration  they  should  be  cautiously  continued.  If  the 
use  of  digitalis  and  strophanthus  is  not  followed  by  good  results  caffein, 
strychnin,  or  camphor  may  be  administered  hypodermically.  In  some 
instances,  where  the  nervous  unrest  is  very  marked,  morphin,  in  1/20  to 
1/50-grain  doses,  given  hypodermically,  acts  very  kindly  and  may  be 
repeated  as  indicated.  Alcohol  in  the  form  of  good  whiskey  or  brandy 
is  of  value.     During  convalescence  iron  and  arsenic  may  be  indicated. 

In  the  treatment  of  acute  cardiac  dilatation,  the  removal  of  four  or 
five  ounces  of  blood  from  the  median  cephalic  vein  may  give  great  relief 
and  tide  the  patient  over  the  attack.  The  application  of  leeches  over 
the  region  of  the  liver  is  also  recommended.  My  own  experience  teaches 
me  that  nitroglycerin  is  preferable  to  bleeding;  it  is  indicated  when  the 
heart  is  in  severe  distress  and  may  be  discontinued  when  the  acute  symp- 
toms threatening  cardiac  paralysis  have  passed  away. 


CHAPTEE  LVII 
CHRONIC    VALVULAR    DISEASE 

Chronic  valvular  disease  is  almost  always  due  to  endocarditis.  This 
applies  to  the  congenital  as  well  as  the  acquired  form.  Xot  infrequently, 
however,  the  primary  attack  of  endocarditis  is  overlooked,  and  the  disease 
first  comes  under  the  observation  of  the  physician  in  its  chronic  form ;  this 
is  especially  true  in  hospital  practice.  In  most  of  these  cases  there  is  a 
history  of  a  previous  attack  of  acute  rheumatism,  or  of  some  other  acute 
disease,  which  leads  to  the  belief  that  acute  endocarditis  occurred  during 
that  attack. 


MITRAL   REGURGITATION"  499 

The  mitral  valve  is  affected  in  about  90  per  cent,  of  the  cases,  and  in 
the  great  majority  the  lesion  is  that  of  mitral  insufficiency.  Mitral  stenosis, 
however,  may  occur  as  an  independent  lesion,  or  insufficiency  and  stenosis 
of  this  valve  may  be  associated.  Aortic  disease,  as  an  independent  lesion, 
is  more  common  in  boys  than  girls.  -  It  is  rare  in  childhood ;  stenosis  is 
more  common  than  insufficiency.  Arteriosclerosis  and  other  causes  of 
aortic  disease  in  the  adult  are  not  present  in  the  child.  Aortic  lesions, 
especially  stenosis,  occur  more  commonly  with  mitral  disease  than  as  in- 
dependent affections.  Chronic  disease  of  the  pulmonary  valves  is  very 
rare  and  usually  congenital. 

Chronic  endocarditis  is  rarely  seen  as  early  as  the  second  or  third 
year  of  life,  but  from  this  time  on  it  occurs  with  increasing  frequency 
throughout  childhood.  Following  an  acute  attack  of  endocarditis,  which 
has  permanently  damaged  the  valves,  especially  the  mitral,  the  young  and 
gi'owing  heart  muscle  of  the  child  rapidly  hypertrophies  to  the  extent 
that  the  lesion  is  largely  compensated.  Under  this  compensation  the 
heart  is  able  to  perform  its  ordinary  physiological  duties  and  the  individual 
may  live  a  useful  and  comparatively  healthful  life,  provided  the  heart  is 
not  overstrained  or  subsequently  damaged  by  a  second  or  third  attack 
of   acute  endocarditis. 

Mitral  Regurgitation. — This  is  the  condition  found  in  the  vast  ma- 
jority of  the  cases  of  chronic  valvular  disease  in  childhood.  The  mitral 
valve  is  incompetent  and  with  each  systole  of  the  ventricle  a  portion  of  the 
blood  is  forced  back  through  the  leaking  valve  into  the  left  auricle;  this 
results  in  dilatation  of  the  auricle,  and,  to  accomplish  the  increased  work 
thrown  upon  them,  both  auricle  and  ventricle  hypertrophy.  If  this  re- 
sults in  complete  compensation  the  circulation  is  maintained,  the  right 
side  of  the  heart  is  protected,  and  all  goes  well,  the  child  suffering  com- 
paratively little  inconvenience  from  the  lesion. 

Sympto:matology. — Compensation,  almost  if  not  quite  complete,  is  the 
condition  usually  found  in  the  chronic  mitral  insufficiency  of  childhood. 
In  these  cases  there  is  a  tendency  to  shortness  of  breath,  rapid  heart 
action,  and  bronchial  cough,  which  is  greatly  exaggerated  by  physical 
exercise.  Well-marked  anemia  may  also  be  present.  In  many  instances 
the  above  symptoms  are  so  slight  as  to  be  almost  or  quite  overlooked,  but 
the  physical  signs  are  very  characteristic.  The  apex  beat,  which  is  dis- 
tinct and  forceful,  is  found  outside  of  the  nipple  line  in  the  fifth  inter- 
costal space.  Auscultation  reveals  a  blowing  systolic  murmur  most  in- 
tense at  or  near  the  apex,  but  very  distinctly  transmitted  to  the  left  below 
the  axilla  in  the  direction  of  the  lower  portion  of  the  scapula.  It  is  one 
of  the  peculiarities  of  this  condition  in  childhood  that  this  murmur  may 
be  heard  almost  as  distinctly  in  the  back,  between  the  lower  spine  of  the 
scapula  and  the  vertebral  column,  as  it  is  in  front.  The  second  sound  of 
the  heart  is  usually  accentuated  over  the  pulmonary  area,  but  if  it  be 
sharply  and  intensely  reduplicated  it  is  an  unfavorable  sign,  indicating 
a   severe   mitral  lesion   with  increased  blood  pressure   in  the   pulmonary 


500 


CHRONIC   VALVULAR   DISEASE 


artery.    An  increase  in  the  size  of  the  heart  downward  and  to  the  left  may 
be  demonstrated  both  by  percussion  and  by  a  radiograph. 

Mitral  Stenosis. — Mitral  stenosis  is  a  much  less  common  but  a  much 
more  serious  lesion  in  childhood  than  mitral  insufficiency.  It  is  usually 
caused  by  repeated  attacks  of  a  low  grade  of  rheumatic  endocarditis.  The 
history  of  rheumatism  elicited  in  these  cases  is  of  the  milder  and  more 
chronic  types,  and  in  some  cases  it  is  entirely  wanting.  The  disease  is, 
as  a  rule,  rather  insidious  in  its  onset,  and,  during  its  early  stages,  espe- 
cially in  younger  children,  some  of  its  characteristic  physical  signs  may  be 
absent.     Jacobi  has  especially  called   attention  to  the  fact  that  mitral 


Fig.  80. — Enlabqed  Heart  from  Mitral  Regdrgitation.     (S.  Lange.) 

stenosis  may  exist  without  the  presence  of  a  diastolic  murmur.  This  con- 
dition is  rare  in  early  childhood,  but  is  much  more  frequently  seen  after 
the  tenth  year.  It  may  exist  as  an  independent  condition,  or  it  may  be 
associated  with  mitral  regurgitation.  Poynton  and  others  note  the  fact 
that  a  systolic  bruit  may  precede  and  then  give  way  to  a  diastolic 
or  presystolic  bruit  as  mitral  stenosis  becomes  well  established.  In  mitral 
stenosis  the  auricle  is  called  upon  to  force  its  blood  stream  through  a  con- 
tracted mitral  opening,  and,  as  a  result,  it  undergoes  dilatation  and  hyper- 
trophy. The  blood  is  dammed  back  into  the  pulmonary  circulation  and 
the  blood  pressure  in  the  pulmonary  artery  is  greatly  increased.  Rapid 
and  sometimes  extensive  hypertrophy  of  the  right  ventricle  results.  This 
hypertrophied  right  ventricle  may  continue  for  a  long  time  to  force  suf- 


AORTIC    STENOSIS  501 

ficient  blood  through  the  pulmonary  circuit  to  supply  the  demands  of  the 
general  circulation  which  is  kept  up  by  the  left  heart,  but  even  under 
these  favorable  conditions  the  left  ventricle  does  not  receive  enough  blood 
to  supply  the  general  circulation,  and,  as  a  result,  this  ventricle,  instead 
of  undergoing  hypertrophy,  as  in  mitral  regurgitation,  may  become  smaller 
or  remain  the  same  size,  so  that  the  apex  beat  in  this  condition  is  not 
displaced.  With  failing  compensation  the  right  ventricle  becomes  dilated 
and  the  general  symptoms  of  cardiac  insufficiency  develop. 

Symptomatology. — This  condition  is  commonly  insidious  in  its  onset. 
Lack  of  development,  anemia,  irritable  heart,  and,  as  Chapin  has  observed, 
pain  in  the  region  of  the  heart  and  dyspnea  on  exercising  are  usually 
present. 

On  auscultation  a  characteristic  rough,  presystolic  murmur  immediately 
precedes  and  is  sharply  terminated  by  a  snapping  first  sound  at  the  apex. 
Its  point  of  greatest  intensity  is  over  the  apex  of  the  heart,  which  is  found 
in  its  normal  position.  The  murmur,  unlike  that  of  mitral  regurgitation, 
is  not  transmitted  toward  the  axillary  line.  The  pulmonic  second  sound 
is  accentuated.  Increase  in  the  size  of  the  heart,  as  shown  by  percussion 
or  by  a  radiograph,  may  be  marked,  and  extends  upward  and  to  the  right 
beyond  the  sternum.  A  presystolic  thrill  may  be  felt  over  the  heart. 
Where  mitral  insufficiency  is  associated  with  mitral  stenosis,  as  it  is  in 
a  large  percentage  of  these  cases,  there  is  a  combination  of  the  physical 
signs  of  the  two  conditions,  with  a  double  murmur  at  the  apex,  the  diastolic 
immediately  preceding  the  systolic  murmur. 

Aortic  Regurgitation. — Aortic  regurgitation  is  rare,  but  is  seen  in  later 
childhood.  Its  characteristic  sign  is  a  diastolic  murmur,  having  its  point 
of  maximum  intensity  in  the  second,  third,  or  fourth  intercostal  space 
near  the  sternum.  It  is  transmitted  downward  along  the  sternum.  The 
heart  is  greatly  enlarged,  due  to  hypertrophy  of  the  left  ventricle.  The 
apex  beat  is  displaced  downward  and  outward,  and  the  cardiac  dullness  is 
increased  in  the  same  direction.  The  greatly  hypertrophied  left  ventricle 
drives  with  great  force  the  blood  stream  into  the  aorta  and  with  the  recoil 
of  this  stream,  due  to  the  defective  valve,  we  have  the  "water-hammer 
pulse,"  characteristic  of  this  condition.  This  is  the  most  serious  of 
cardiac  lesions,  usually  resulting  fatally  before  or  about  the  time  of  puberty. 
The  symptoms  of  cardiac  insufficiency  are  much  more  commonly  present 
than  in  mitral  lesions.  Pallor,  stunted  growth,  rapid,  irregular  pulse, 
dyspnea,  and  cyanosis  are  common,  and.  with  the  breaking  down  of  the 
partial  compensation,  the  symptoms  of  gradual  cardiac  failure  appear. 
Sudden  death  may  occur  in  these  cases. 

Aortic  Stenosis. — This  is  also  a  rare  condition  and  is  not  uncommonly 
associated  with  aortic  regurgitation.  The  characteristic  bruit  is  a  harsh, 
systolic  murmur  heard  most  distinctly  in  the  second  right  interspace  near 
the  sternum  and  is  transmitted  upward  into  the  large  arteries  of  the  neck. 
The  hand  on  the  chest  feels  a  distinct  systolic  thrill.  The  left  ventricle 
is  hypertrophied,  the  apex  beat  is  displaced  downward  and  outward,  and 


502  CHROXIC  VALVULAR   DISEASE 

an  increased  dullness  may  be  outlined  in  the  same  directions.  The  symp- 
toms of  cardiac  incapacity  are  the  same  as  those  above  noted  in  aortic 
regurgitation. 

Tricuspid  Regurgitation. — Tricuspid  regurgitation  occurs  in  congenital 
conditions  and  as  a  late  development  of  failing  compensation  in  mitral 
and  aortic  disease.  Apart  from  these  conditions  it  is  almost  unknown 
in  childhood.  It  is  characterized  by  a  systolic  murmur  heard  over  the 
lower  portion  of  the  sternum. 

Failing  Compensation. — Failing  compensation  may  result  from  the  se- 
riousness of  the  valve  lesion  itself,  from  too  severe  physical  strain  thrown 
upon  the  heart,  or  from  repeated  attacks  of  endocarditis.  In  this  condition 
the  blood  is  dammed  back  into  the  pulmonary  circulation,  producing  a 
great  increase  in  the  blood  pressure  of  the  pulmonary  artery,  which  causes 
a  sharp,  quick  closing  of  this  valve,  reduplication  of  the  second  sound,  and 
later  incompetency  of  the  tricuspid  valve.  It  will  thus  be  seen  that  the 
giving  way  of  the  heart  in  chronic  valvular  disease  may  first  be  indicated 
by  a  marked  accentuation  and  reduplication  of  the  second  sound  over  the 
pulmonary  valve,  and  later  by  a  marked  dilatation  of  the  heart  with  a 
displacement  of  the  apex  beat  downward  and  outward.  This  great  increase 
in  the  size  of  the  heart,  which  occurs  in  failing  compensation,  results  in 
the  development  of  other  murmurs,  associated  with  the  aortic,  and  possibly 
the  pulmonary,  valves.  The  great  enlargement  of  the  heart  in  this  con- 
dition may  be  seen  in  a  radiograph,  or  made  out  by  percussion.  Asso- 
ciated with  the  great  increase  in  the  area  of  cardiac  dullness,  the  apex 
beat  is  diffuse  and  the  vibrations  of  the  struggling  heart  may  be  seen  and 
felt  in  the  intercostal  spaces.  In  these  cases  the  pulse  beat  is  irregular 
and  rapid;  dyspnea,  orthopnea  and  cyanosis  are  present.  The  legs  may 
be  slightly  swollen,  and  in  some  instances  a  general  anasarca  may  de- 
velop, the  abdominal  cavity  being  filled  with  fluid.  This  gradual  failure 
of  compensation,  resulting  in  death,  is  unusual  in  childhood.  It  much 
more  commonly  occurs  at  or  after  puberty. 

Prognosis  of  Chronic  Valvular  Disease. — The  prognosis  of  chronic  val- 
vular disease  depends  upon  the  following  conditions:  first,  the  valve 
affected;  second,  the  extent  of  the  valvular  lesion;  third,  the  complete- 
ness of  the  resulting  compensation;  fourth,  the  possibility  of  preventing 
recurring  attacks  of  endocarditis;  fifth,  the  proper  regulation  of  the  life 
of  the  child,  so  that  he  may  have  proper  exercise  without  throwing  se- 
vere strain  at  any  time  upon  the  heart  muscle. 

The  prognosis  is  best  in  uncomplicated  mitral  regurgitation.  In 
many  of  these  cases  compensation  may  be  so  complete  that  the  heart  is 
physiologically  competent  to  carry  on  the  circulation  under  the  ordinary 
conditions  of  life,  so  that  these  individuals  may  be  useful  members  of  a 
community  throughout  a  long  life.  In  mitral  stenosis  the  prognosis  is 
usually  not  so  good,  and  there  is  more  danger  that  the  heart,  even  in  the 
favorable  cases,  may  show  a  failing  compensation  at  or  about  pubert)'.  In 
aortic  disease  the  prognosis  is,  as  a  rule,  bad,  as  few  of  these  cases  live  to 


TEEATMENT    OF    CHRONIC    VALVULAR   DISEASE      503 

be  useful  niemljers  of  a  community;  they  commonly  die  in  later  child- 
hood or  about  puberty.  Where  more  than  one  valve  is  affected  the  gravity 
of  the  prognosis  is  greatly  increased. 

The  extent  of  the  valvular  lesion  can  commonly  be  estimated  by  the 
displacement  of  the  apex  beat,  the  degree  of  cardiac  hypertrophy  and 
dilatation,  and  by  symptoms  pointing  to  increased  blood  pressure  in  the 
pulmonary  artery.  The  gravity  of  the  prognosis  is  in  direct  proportion 
to  the  severity  of  these  signs  and  sj'mptoms. 

When  complete  compensation  has  been  established  and  all  symptoms 
of  cardiac  irritation  have  subsided  and  the  child  is  able  to  resume  his 
ordinary  vocations  without  cardiac  distress,  the  prognosis  is  good,  and 
it  is  correspondingly  bad  when,  after  proper  and  prolonged  treatment, 
complete  compensation  cannot  be  established. 

Treatment  of  Chronic  Valvular  Disease. — The  most  important  factor  in 
the  prognosis,  in  those  cases  in  which  compensation  has  been  established, 
is  the  possibility  or  probability  of  preventing  recurring  attacks  of  endo- 
carditis. In  accomplishing  this  end  the  cause  of  the  previous  endocarditis 
must  be  taken  into  consideration.  In  the  great  majority  of  these  cases 
rheumatism  is  the  exciting  factor,  and  the  treatment,  therefore,  largely 
consists  in  the  prevention  of  subsequent  attacks.  These  children  should, 
if  possible,  for  a  number  of  years  avoid  the  cold,  damp,  changeable  weather 
which  prevails  during  the  winter  months  in  our  middle  and  northern 
States,  by  spending  the  months  of  January,  February  and  March  in  a 
warm,  dry,  and  equable  climate.  Those  children  that  are  compelled  to 
remain  under  unfavorable  climatic  conditions  should,  during  the  winter 
months,  wear  woolen  underclothing,  sleep  in  well-ventilated  apartments, 
and  in  suitable  weather  spend  a  great  portion  of  the  day  out  of  doors, 
being  always  careful  to  avoid  damp  cold.  It  is  especially  important  that 
they  should  be  properly  shod  so  that  their  feet  may  be  always  dry  and 
warm.  Above  all,  they  should  not  be  allowed  to  go  to  school  or  be  closely 
housed  with  other  children  where  the  air  is  bad  and  contagions  are  pres- 
ent. All  diseases  that  in  any  way  involve  the  throat  and  respiratory  pas- 
sages are  especially  dangerous,  and  every  effort  should  therefore  be  made 
to  protect  them  from  contagious  diseases,  especially  influenza  and  ton- 
sillitis. 

In  the  treatment  of  chronic  valvular  heart  disease  it  is  especially  im- 
portant to  remember  the  close  relationship  which  exists  in  many  of  these 
cases  between  tonsillitis  and  recurring  endocarditis.  Every  child  with  a 
compensated  heart  lesion  should  have  the  tonsils  and  other  lymphoid  tissues 
in  his  throat  and  pharynx  carefully  inspected.  If  the  tonsils  and  adenoids 
be  enlarged  or  diseased,  they  should  be  removed  during  the  spring  or  sum- 
mer months,  and  the  adenoid  ring,  of  which  they  are  a  part,  should  there- 
after be  kept  in  as  healthful  a  condition  as  possible,  to  prevent  the  entrance 
of  the  contagion  of  rheumatism  and  other  acute  infections. 

Avoidance  of  heart  strain  is  a  most  important  measure  in  preventing 
the  breaking  down  of  compensation.     To  accomplish  this  the  child  must 


504  CHRONIC    VALVULAK    DISEASE 

be  under  such  proper  medical  supervision  that  he  may  have  prescribed  for 
him  the  exercise  necessary  to  the  development  of  the  heart  without  pro- 
ducing cardiac  strain.  The  careful  medical  observer  can,  as  a  rule,  toll 
the  child  what  he  should  do  in  the  way  of  physical  exercise,  but  he  is  not 
always  so  fortunate  as  to  have  his  directions  carefully  followed.  The  heed- 
lessness of  childhood  and  ofttimes  the  carelessness  of  parents  are  factors 
over  which  he  has  no  control.  The  importance  of  this  subject  demands 
that  he  should  give  explicit  directions,  and  not  vague  statements,  with 
reference  to  exercise,  and  that  he  should  impress  upon  the  parents,  as 
well  as  the  child,  the  absolute  necessity  of  following  directions.  No 
general  rule  as  to  the  kind  of  sports  and  the  character  of  exercise  can  be 
made  which  will  apply  to  all  cases  of  heart  disease;  each  case  must  be 
studied  individually  and  prescribed  for  accordingly.  If  the  lesion  be  a 
mitral  one  and  complete  compensation,  without  great  enlargement  of  the 
heart,  has  followed,  it  is  probable  that  a  return  to  the  ordinary  sports  of 
childhood  may  be  gradually  accomplished  without  injury  to  the  heart. 
Golf,  horseback-riding,  swimming,  a  moderate  amount  of  ball-playing  may 
in  time  be  safely  indulged  in,  but  at  no  time,  even  in  these  favorable  cases, 
should  tennis  playing,  hard  bicycle  riding  or  endurance  contests  of  any 
kind,  such  as  running,  rowing  or  rope  jumping,  be  permitted.  It  sbould 
be  remembered,  moreover,  that  it  is  only  the  most  favorable  cases  of 
fully  compensated  mitral  insufficiency  that  can  be  allowed  this  freedom 
in  outdoor  sports.  In  most  of  the  cases  the  exercise  should  be  much  more 
restricted  throughout  childhood,  and  the  parents  as  well  as  the  ])atients 
should  be  told  that  the  greatest  danger  of  failing  conij)ensation  occurs  at 
or  about  puberty,  and  that  for  this  reason  the  heart  muscle  must  be  kept 
in  as  good  a  condition  as  possible,  by  gentle  exercise  and  by  avoiding  heart 
strain,  that  this  critical  period  may  be  safely  passed. 

The  general  regulation  of  the  life  of  the  child  is  important.  Nutrition 
must  be  especially  looked  to,  by  giving  suitable  food  at  regular  intervals. 
An  excess  of  sweets  is  to  be  avoided;  sugar  in  the  form  of  candy,  confec- 
tions, and  pastry  may  do  much  harm.  The  diet  should  be  a  general  one 
consisting  of  vegetables,  eggs,  milk,  cereals,  fruit,  and  a  moderate  amount 
of  meat.  Disturbances  of  digestion,  and  constipation,  should  be  carefully 
guarded  against.  Severe  nervous  and  mental  strain,  such  as  may  be  asso- 
ciated with  school  work,  is  to  be  avoided;  tliese  children  are  easily  excited, 
and  their  nervous  systems  readily  break  down  from  overwork  and  excite- 
ment. They  require  more  rest  than  the  normal  child ;  they  should  go 
to  bed  early,  and  during  the  day,  if  there  be  the  least  sensation  of 
fatigue,  they  should  be  required  to  lie  down  after  their  midday  meals ;  this 
applies  even  to  those  cases  where  compensation  is  apparently  complete. 

Systematic  medical  treatment  may  be  important.  This  ajjplies  espe- 
cially to  those  cases  in  which  rheumatism  is  the  etiological  factor.  It 
consists  largely  in  the  giving  of  alkalies  and  the  salicylates  during  the 
winter  months  for  a  number  of  years  following  the  initial  attack  of  endo- 
carditis.    Bicarbonate,  or  benzoate,  of  soda,  5  to  10  grains,  may  l^e  com- 


TREATMENT    OF    CHROXIC    VALVULAR  DISEASE      505 

hined  with  (wintergreen)  salicylate  of  soda,  3  to  5  grains,  put  up  in  a 
palatable  vehicle.  This  should  be  given  for  one  week  in  every  month,  and 
during  the  remaining  time  the  child  should  drink  alkaline  waters. 

If  anemia  is  present,  iron,  arsenic,  and  cod-liver  oil  may  be  of  benefit, 
but  the  presence  of  this  symptom  usually  indicates  an  incomplete  com- 
pensation, or  the  occurrence  of  some  complicating  disease,  and  in  either 
event  its  cause  demands  careful  study,  and  the  resulting  treatment  will 
depend  upon  the  cause.  If  well-marked  anemia  occurs,  the  child  should 
be  put  to  bed  the  greater  portion  of  the  day  and  night  in  the  fresh  air 
out  of  doors,  or  with  the  bedroom  windows  wide  open;  this,  with  careful 
feeding,  and  the  above-named  tonics,  will  produce  a  rapid  improvement  in 
the  blood  state. 

Treatment  of  Incomplete  or  Failing  Compensation. — In  the  foregoing 
sketch  of  the  treatment  of  chronic  heart  disease  with  full  compensation,  no 
mention  has  been  made  of  the  use  of  digitalis  or  other  heart  tonics,  be- 
cause they  are  not  indicated  when  compensation  is  complete.  Great  harm 
may  be  done  by  the  unnecessary  administration  of  these  drugs  to  a  patient 
whose  heart  muscle  is  fully  capable  of  doing  its  work ;  a  heart  murmur  is, 
therefore,  not  always  an  indication  for  heart  stimulants.  When  the  symp- 
toms of  incomplete  or  failing  compensation  are  present,  these  heart  stim- 
ulants, properly  administered,  in  association  with  rest  in  bed,  are,  as  a 
rule,  necessary,  but  above  all  I  wish  to  impress  the  fact  that  in  these  cases 
rest  in  bed  should  be  the  first  order,  and  heart  stimulants  the  second.  It 
is  a  fatal  mistake  to  try  to  overcome  the  rapid,  irregular  pulse  and  short- 
ness of  breath  of  children  with  chronic  heart  disease,  by  giving  them 
digitalis  and  allowing  them  to  remain  upon  their  feet.  Rest  in»  bed  is 
the  all-important  remedy,  just  as  it  is  in  acute  cardiac  affections.  During 
the  time  the}-  are  confined  to  bed,  and  for  some  time  thereafter,  heart 
stimulants  are  of  value.  The  best  of  these  is  digitalis;  it  may  be  given 
in  the  form  of  the  tincture,  from  3  to  6  drops,  depending  upon  the  age 
of  the  child;  care,  however,  being  taken  that  its  administration  does  not 
disturb  the  stomach.  The  fat-free  tincture  may,  as  a  rule,  be  adminis- 
tered in  essence  of  pepsin  over  a  long  period  of  time  without  producing 
gastric  disturbance.  In  some  cases  it  may  be  necessary  to  substitute  tea- 
spoonful  doses  of  the  fresh  infusion  of  digitalis,  or  from  3-  to  5-drop  doses 
of  the  tincture  of  strophanthus.  The  latter  remedy,  while  not  as  reliable 
as  digitalis  in  bringing  about  compensation,  is  of  much  more  value  in  the 
child  than  it  is  in  the  adult,  and  serves  a  very  useful  purpose  in  those 
cases  where  digitalis  disturbs  the  stomach.  It  should  also  be  remembered 
that  the  action  of  digitalis  is  cumulative,  and  for  this  reason  its  adminis- 
tration should  be  interrupted  from  time  to  time,  to  be  again  resumed  when 
the  heart  begins  to  flag.  Sulphate  of  str)'chnin,  1/100  to  1/200  of  a  grain, 
may  be  of  value  as  a  respiratory,  cardiac  and  general  tonic,  if  given  over 
a  considerable  period  of  time.  In  those  cases  that  do  not  respond  fully 
to  the  rest  and  digitalis  treatment,  and  which  stop  slightly  short  of  full 
compensation,  the  home  administration  of  the  Nauheim  bath,   which   is 


506  FU^^CTIONAL  CARDIAC  DISORDEKS 

of  such  value  in  the  treatment  of  myocardial  insufficiency  in  the  adult,  may 
be  tried.  These  baths  are  especially  applicable  in  older  children,  and  the 
rules  governing  their  administration  should  be  the  same  as  those  outlined 
in  the  treatment  of  myocardial  insufficiency  in  the  adult.  In  those  unusual 
cases  of  chronic  myocardial  insufficiency  associated  with  well-marked 
dropsy  the  amount  of  fluid  taken  by  the  patient  should  be  restricted,  if 
possible,  to  one  quart  in  the  twenty-four  hours.  In  these  cases  all  the  fluid 
taken  should  be  carefully  estimated,  so  that  the  sum  of  all  the  water  and 
liquid  foods  should  not  exceed  this  amount. 

If  marked  ascites  is  present,  paracentesis  gives  great  relief,  and  is  fol- 
lowed by  improvement  in  the  action  of  the  heart.  In  this  operation  the 
same  precaution  should  be  taken  as  in  the  adult,  the  fluid  being  slowly 
withdrawn  and  the  abdominal  wall  subsequently  firmly  supported  by  an 
abdominal  bandage. 


CHAPTER    LVIII 
FUNCTIONAL    CARDIAC    DISORDERS 

Disturbances  in  the  rate  and  rhythm  of  the  heart's  action,  not  asso- 
ciated with  inflammatory  disease  of  this  organ,  are  common.  The  child, 
by  reason  of  the  immaturity  and  instability  (lack  of  inhibition)  of  its 
nervous  system,  is  normally  predisposed  to  functional  disorders  of  the 
heart,  and  this  predisposition  may  be  greatly  increased  by  a  neurotic  in- 
heritance and  by  anemia  and  general  malnutrition.  In  children  of  this 
type  the  cardiac  nervous  mechanism  is  easily  disturbed  by  reflex  and  toxic 
factors,  such  as  are  commonly  present  in  gastrointestinal  disturbances 
and  the  acute  infections. 

Arrhythmia. — Arrhythmia,  or  irregularity  in  the  heart's  action,  is  com- 
mon in  infancy  and  childhood,  and  has,  as  a  rule,  little  pathological  sig- 
nificance. It  may  occur  in  nervous  children  even  during  sleep,  from  slight 
or  unknown  exciting  causes.  It  may  result  from  fright,  anger  or  nervous 
excitement  of  any  kind;  a  cold  bath,  severe  exercise,  slight  fevers,  and 
bacterial  intoxications  may  produce  more  or  less  irregularity  in  the 
rhythm  of  the  heart's  action ;  a  variation  of  20  to  30  beats  may  occur  within 
a  few  minutes  without  special  pathological  significance.  Palpitation  of 
the  heart,  associated  with  pain  in  the  side  and  shortness  of  breath  on 
exercise,  is  not  uncommon  in  nervous,  anemic,  rapidly  growing  children. 
As  elsewhere  noted,  it  is  not  improbable  that  the  explanation  for  the  asso- 
ciation of  certain  cardiac  neuroses  in  older  children  with  their  rapid 
growth  may  be  due  to  the  excessive  action  of  the  thyroid  gland  during 
this  period  of  life,  the  increased  function  of  this  gland  being  responsible 
in  part,  at  least,  for  both  the  rapid  growth  and  the  cardiac  irritability. 

Paroxysmal  Tachycardia. — Paroxysmal  tachycardia  may  occur  in  older 
children.     These  attacks  are  commonly  produced  by  auto-  or  intestinal 


FUXCTIOXAL   HEAET    MUEMUES  507 

toxins.  They  are  not  infrequentlj*  associated  with  constipation,  coated 
tongue,  bad  odor  to  the  breath,  headache,  perspiration,  and  sometimes  with 
an  elevation  of  temperature.  A  gouty  or  migrainous  diathesis  may  be 
etiologically  related  to  these  cases,  and  masturbation  may  be  a  predis- 
posing factor.  I  have  seen  this  symptom  group  associated  with  attacks 
of  recurrent  coryza. 

Bradycardia. — Bradycardia,  or  slow  heart  action,  may  also  occur  as  a 
purely  reflex  disorder  in  nervous,  malnourished,  neurotic  children.  The 
exciting  cause  in  these  cases  is  commonly  of  intestinal  origin.  The  asso- 
ciation, however,  of  bradycardia  and  arrhythmia  occurring  in  certain  of  the 
acute  infections,  such  as  diphtheria  and  influenza,  may  be  of  ominous  sig- 
nificance, denoting  a  toxic  myocarditis  rather  than  a  simple  functional 
disturbance. 

Functional  Heart  Murmurs.  — Accidental  and  functional  heart  murmurs 
are  very  common  in  early,  as  w-ell  as  in  late,  childhood.  They  very  often 
have  no  apparent  pathological  significance ;  they  may  be  hemic,  due  to  pro- 
found anemia;  they  may  be  myocardial,  resulting  from  malnutrition,  irri- 
tation, defective  innervation,  or  inflammation  of  the  heart  muscles,  or  they 
may  be  cardiopulmonary  in  character. 

The  most  common  accidental  murmur  is  the  "late  systolic  pulmonary 
murmur,"  spoken  of  by  many  writers  and  carefully  described  by  Hamill 
and  le  Boutillier.  It  is  soft-blowing  in  character,  moderately  high  pitched, 
and  is  continuous  with,  or  immediately  follows,  the  first  sound.  This  sys- 
tolic murmur  has  its  point  of  maximum  intensity  in  the  second  left  inter- 
space close  to  the  sternal  border,  but  it  may  be  distinctly  heard  lower  down 
in  the  third  and  fourth  spaces  between  the  midclavicular  and  parasternal 
lines.  It  is  best  heard  in  the  recumbent  position,  at  the  end  of  inspira- 
tion; it  may  entirely  disappear  upon  forced  inspiration,  and  is  exaggerated 
by  exercise.  The  position  of  the  apex  beat  of  the  heart  is  not  altered, 
and  the  area  of  heart  dullness  is  not  increased.  It  may  be  transmitted  to 
the  vessels  in  the  neck  and  is  usually  associated  with  a  venous  hum  over 
both  sides  of  the  neck.  Hamill  says  that  this  murmur  has  no  definite 
pathological  significance.  It  may  occur  in  the  absence  of  anemia,  but 
"unquestionably  the  conditions  giving  rise  to  this  murmur  are  frequently 
associated  with  anemia."  Liithje,  Hamill,  and  le  Boutillier  found  this 
murmur  in  over  60  per  cent,  of  institutional  children  under  five  years  of 
age;  it  is  therefore  of  the  greatest  importance  that  it  should  be  carefully 
differentiated  from  bruits  produced  by  organic  disease  of  the  heart.  In 
making  this  differentiation  it  should  be  remembered  that  it  is  not  con- 
genital and  that  it  is  aggravated  by  the  recumbent  posture,  is  loudest  at 
the  end  of  expiration,  and  commonly  disappears  when  the  lungs  are  fully 
inflated.  The  location  of  the  murmur,  the  normal  position  of  the  apex 
beat,  and  the  normal  area  of  cardiac  dullness  are  most  important. 

Forchheimer  has  especially  emphasized  the  fact  that  mild  forms  of 
acute  myocarditis  occurring  in  scarlet  fever,  diphtheria,  typhoid,  rheu- 
matic fever,  variola,  gonorrhea,  septicopyemia,  acute  nephritis,  and  other 


508  FUNCTIONAL  CARDIAC  DISORDERS 

acute  infections  characterized  by  fever  may  produce  transient,  systolic, 
apical  bruits  which  disappear  when  the  myocardium  recovers  from  the 
irritation  produced  by  the  acute  toxemia.  Systolic  bruits  from  this  cause 
have  their  point  of  greatest  intensity  at  the  apex,  and  are,  as  a  rule,  not 
transmitted  to  the  axillary  line.  It  is  most  important  to  keep  in  mind  the 
conditions  under  which  this  character  of  heart  bruit  may  occur,  and  it  is 
always  wise  in  these  cases  to  withhold  a  definite  prognosis  until  the  condi- 
tion of  the  heart  may  be  studied  after  the  acute  intoxication  has  disap- 
peared, since  in  many  of  these  cases  it  will  be  found  that  what  seemed  a 
simple  myocardial  bruit  is  later  found  to  be  due  to  a  true  endocarditis. 
This  type  of  cardiac  murmur  is  not  infrequently  associated  with  chorea. 

The  cardiopulmonary  murmur  produced  by  the  movement  of  the  air 
in  that  portion  of  the  lung  which  is  in  direct  contact  with  the  heart  is 
systolic  in  time  and  heard  with  maximum  intensity  at  the  apex  along  the 
left  border  of  the  heart.  It  is  inconstant,  heard  loudest  at  the  end  of 
expiration,  and  is  comparatively  infrequent,  especially  in  the  young  child. 

Venous  murmurs  occur  both  in  infancy  and  childhood.  They  are  most 
commonly  heard  over  the  large  veins  of  the  neck;  they  may  be  associated 
with  anemia,  glandular  tuberculosis,  enlarged  thymus,  rickets,  and  other 
malnutritions.  The  venous  murmur  described  by  Eustace  Smith  has  long 
been  recognized;  it  is  produced  by  the  pressure  of  enlarged  glands  upon 
the  innominate  veins,  and  is  made  much  more  distinct  by  throwing  the 
head  of  the  child  backward;  by  this  movement  the  enlarged  glands,  back 
of  the  veins,  push  them  forward  and  compress  them  against  the  manubrium 
sterni. 

In  the  diagnosis  of  functional  murmurs,  it  is  important  to  remember 
that  diastolic  bruits  are  nearly  always  organic,  and  that,  as  Forchheimer 
says,  "The  accentuation  of  the  second  pulmonary  sound  is  of  little  value 
for  diagnostic  purposes,  first,  because  it  so  frequently  occurs  in  children 
who  have  no  heart  disease,  and,  secondly,  it  exists  in  both  organic  and 
functional  valvular  conditions  in  older  children." 

Prognosis  of  Functional  Cardiac  Disorders, — The  prognosis  in  purely 
functional  endocardial  murmurs  is  good.  The  prognosis  in  venous  mur- 
murs will  depend  upon  the  exciting  cause. 

Treatment. — Severe  exercise  is  to  be  prohibited;  moderate  exercise  out 
of  doors  is  of  great  value  in  restoring  the  tone  of  the  heart  muscle.  The 
malnutrition,  anemia  and  nervousness  in  these  cases  is  to  be  combated  by 
living  and  sleeping  out  of  doors;  by  a  carefully  regulated  diet  of  easily 
digested  foods,  including  milk,  eggs  and  meat ;  and  by  such  tonics  as  iron, 
arsenic  and  cod-liver  oil.  The  individual  case  in  every  instance  must  be 
studied  to  determine  the  important  underlying  causes  of  the  cardiac  neu- 
rosis. In  many  instances  constipation  and  gastrointestinal  toxemia  are 
to  be  carefully  combated.  In  others  the  anemia  requires  treatment.  In 
others  some  profound  constitutional  disturbance,  such  as  tuberculosis, 
may  have  to  be  combated.  While  the  curative  treatment  is  being  directed 
toward  the  removal  of  the  underlying  causes,  it  may  be  necessary  for  a  time 


PATHOLOGY  509 

to  give  nerve  sedatives,  such  as  the  bromides  or  valerian,  and  in  rare  in- 
stances digitalis  may  be  demanded. 


CHAPTER    LIX 
PERICAEDITIS 

Pericarditis  is  an  inflammation  of  the  pericardinm,  which  in  childhood 
is  usually  associated  with  endocarditis,  the  two  conditions  having  very 
much  the  same  etiological  factors. 

Etiology. — It  may  occur  in  utero,  is  not  uncommon  during  the  first 
year  of  life,  and  is  met  with  in  increasing  frequency  throughout  child- 
hood. Acute  rheumatism  is  the  most  common  direct  etiological  factor; 
rheumatic  polyarthritis  and  chorea  are  associated  with  a  large  percentage 
of  the  cases.  Scarlet  fever,  sepsis,  pneumonia,  tuberculosis,  and  other  acute 
and  chronic  infections  may  be  exciting  causes.  Pericarditis  may  be  pro- 
duced by  the  transference  of  the  infectious  material  through  the  blood  or 
lymph  channels,  or  by  direct  infection  from  contiguous  diseased  struc- 
tures in  the  lungs,  pleura  or  heart  itself.  Hochsmger  says  it  is  a  pe- 
culiarity of  the  pericarditis  of  childhood  that  in  infancy  it  depends  chiefly 
upon  pyemic  infection,  in  early  childhood  mainly  upon  the  spread  of  in- 
flammatory processes,  and  in  later  childhood  upon  rheumatism,  which  may 
be  associated  with  chorea ;  the  exudate,  therefore,  in  infancy  is  usually 
purulent;  in  early  childhood  generally  serofibrinous,  and  in  later  child- 
hood almost  always  purely  fibrinous.  The  microorganisms  most  common- 
ly found  are  pneumococci,  streptococci,  staphylococci,  tubercle,  colon  and 
pyocyaneus  bacilli. 

Pathology. — The  pathological  anatomy  is  similar  to  that  found  in  the 
adult.  There  are  three  varieties.  The  fibrinous  variety  is  characterized 
by  a  fibrinous  exudate  covering  both  the  visceral  and  parietal  pericardium, 
the  rough  surfaces  of  which  are  rubbed  together  by  the  action  of  the  heart, 
producing  the  to-and-fro  friction  rub.  The  serofibrinous  variety  is  the 
same  as  the  above,  with  the  addition  of  a  serous  exudate,  which  as  it  col- 
lects gradually  separates  the  roughened  surfaces  of  the  pericardium;  in 
some  instances  there  may  be  an  enormous  dilatation  of  the  sac.  These  two 
varieties  are  commonly  but  different  phases  of  the  same  pathological  pro- 
cess, and  rheumatism  is  the  all-important  etiological  factor.  In  the  puru- 
lent variety  the  exudate  is  composed  of  pus  or  seropus.  which  may  be 
tinged  with  blood.  In  some  of  these  cases  miliary  tubercles  may  infiltrate 
the  pericardium,  in  others  the  disease  may  be  associated  with  pneumonia 
or  purulent  pleurisy.  Again,  a  simple  serofibrinous  pericarditis  may  be 
converted  into  the  purulent  form.  Endocarditis  and  myocarditis  are  very 
commonly  associated  wdth  pericarditis.  With  the  absorption  of  the  fluid 
and  the  subsidence  of  the  inflammation,  adhesions  may  occur  between  the 
pericardial  layers,  which  greatly  cripple  the  action  of  the  heart.    Rarely  in 


510  PERICAEDITIS 

mild   forms  of  pericarditis,  due  to  rheumatism,  there  may  he  complete 
restoration  of  the  parts. 

Symptomatology. — Pericarditis  is  frequently  a  very  obscure  condition, 
and  its  recognition  is  ofttimes  difficult;  in  many  instances  the  diagnosis  is 
made  on  the  post-mortem  table.  Mistakes  in  diagnosis  may  be  due  to  the 
fact  that  there  is  a  complicating  endocarditis  or  myocarditis,  and  the  symp- 
tom group  is  thereby  confused,  but  in  most  instances  they  are  due  to  lack 
of  careful  physical  examination.  The  general  symptoms,  while  not  char- 
acteristic, are  important  and  suggestive.  Fever  is  nearly  always  present; 
in  the  fibrinous  and  serofibrinous  varieties  it  may  not  rise  above  101°  or 
102  °F.  In  the  purulent  form  it  is  remittent  or  intermittent  in  character, 
running  as  high  as  104°  or  105° F.,  and  perhaps  falling  within  the  day  to 
normal  or  below;  this  type  of  temperature,  associated  with  other  signs  of 
cardiac  disease,  commonly  means  either  a  septic  endo-  or  pericarditis,  apd 
the  physical  signs  must  make  the  differentiation.  In  pericarditis  there 
may  be  and  commonly  is  palpitation,  precordial  pain  and  more  or  less 
marked  dyspnea,  sometimes  amounting  to  orthopnea;  the  pulse  is  rapid, 
frequently  reaching  130  or  160,  and  not  infrequently  cyanosis  and  marked 
acceleration  of  the  respiratory  movements  are  present.  The  above  symptom 
group  should  suggest  pericarditis,  rather  than  a  simple  endocarditis;  the 
same  symptom  group,  however,  may  be  present  in  myocarditis  with  acute 
dilatation.  It  should  be  remembered,  however,  that  not  every  case  of 
pericarditis  is  marked  by  the  above  symptoms  of  cardiac  distress;  in  some 
instances  the  disease  is  very  insidious  in  its  onset,  and  may  not  be  suspected 
until  physical  signs  reveal  its  presence. 

Physical  Signs. — A  to-and-fro  friction  rub,  synchronous  with  the 
heart's  action,  is  the  most  typical  sign  of  this  disease.  In  the  beginning 
it  is  usually  soft  and  later  becomes  hard  and  grating;  it  is  commonly 
heard  best  over  the  base,  and  firm  pressure  with  the  stethoscope  may  make 
it  more  distinct.  Change  of  position  may  cause  it  to  vary  in  intensity; 
it  is  least  distinct  with  the  child  lying  upon  its  back,  and  is  commonly 
exaggerated  when  the  child  sits  up  or  leans  forward.  In  most  instances 
it  lacks  constancy  and  does  not  continue  to  be  synchronous  with  the  to- 
and-fro  action  of  the  heart;  it  may  be  heard  only  during  systole,  or  com- 
plete intermittency  may  occur.  As  effusion  occurs  it  becomes  less  and  less 
distinct,  finally  disappearing  altogether  as  the  layers  of  the  pericardium  are 
separated.  In  these  cases  the  rub  may  sometimes  be  again  discovered  and 
the  apex  beat  again  be  felt  by  placing  the  child  in  the  knee-elbow  position. 
With  the  disappearance  of  the  friction  sound,  due  to  the  increase  of  exu- 
date in  serous  and  purulent  pericarditis,  the  heart  sounds  are  muffled,  the 
apex  beat  becomes  fainter,  more  diffused  and  may  entirely  disappear. 
With  the  absorption  of  the  exudate,  the  heart  sounds  again  become  more 
distinct,  the  friction  rub  returns  to  remain,  for  a  time,  until  convalescence 
is  fully  established  and  recovery  has  resulted  either  in  complete  absorption 
of  the  fibrinous  exudate  or  in  adhesions  between  the  pericardial  layers. 

Where  the  pericardial  effusion  is  great,  inspection  may  reveal  a  bulging 


DTAOXOSTS 


511 


over  the  cardiac  area,  and  percus!>ion  i?hows  a  very  great  increase  of  the 
cardiac  dullness,  which  may  extend  as  high  as  the  second  rib,  an  inch  to 
the  left  of  the  sternum,  curving  from  that  point,  well  outside  the  nipple 
line  and  normal  apex  beat,  as  low  as  the  sixth  or  seventh  rib.  To  the 
right  the  dullness  may  extend  2  cm,  or  more  beyond  the  sternum,  and,  con- 
tinuing downward,  become  continuous  with  the  liver  dullness.  The  out- 
lines of  the  distended  pericardial  sac  are  clearly  shown  by  radiography. 


Fig.  81. — Pericarditis  with  Effusion.     (S.  Lange.) 

In  fatal  cases  the  anemia  deepens  to  a  marked  pallor,  the  dyspnea 
becomes  an  orthopnea,  the  cardiac  pain  is  more  marked,  the  patient  is  rest- 
less, sleepless,  and  vomiting  occurs.  The  area  of  cardiac  dullness  may 
increase  enormously,  the  liver  becomes  enlarged,  the  pleura  fills  with  fluid, 
the  urine  is  scant  and  albuminous,  the  pulse  is  rapid,  irregular  and  flicker- 
ing.   Somnolence  and  coma  may  end  the  scene. 

Diagnosis. — There  should  be  little  difficulty  in  differentiating  endo- 
carditis from  pericarditis,  except  in  those  cases  where  the  two*  conditions 
occur  at  the  same  time.  In  endocarditis  the  physical  signs  are  constant 
and  little  influenced  from  day  to  day  by  changes  in  the  condition  of  the 
heart,  while  in  pericarditis  the  variability  in  the  physical  signs,  from  day 
to  day,  is  noteworthy.  The  murmurs  in  these  two  conditions  differ  in  their 
character,  location  and  point  of  intensity,  and  differ  especially  in  the  fact 
that  the  murmur  of  endocarditis  is  transmitted,  while  the  friction  rub  of 
pericarditis  is  not  conducted,  but  is  confined  largely  to  the  base  of  the 
heart  and  always  to  the  pericardial  region.  The  differential  diagnosis, 
however,  between  pericardial  effusion  and  acute  dilatation  of  the  heart  is 
ofttimes  a  matter  of  great  difficulty.  The  pericardial  rub  being  absent, 
both  conditions  may  present  the  marked  increase  in  the  area  of  cardiac 
3-1 


512  PERICARDITIS 

dullness,  with  the  symptoms  of  cardiac  distress.  In  acute  dilatation,  how- 
ever, these  symptoms  appear  more  rapidly,  and  in  this  condition  also, 
palpation  over  the  cardiac  area  reveals  a  cardiac  thrill,  and  the  apex  beat, 
while  faint  and  diifused,  can  readily  be  located  by  placing  the  patient  in 
the  knee-elbow  position. 

Prognosis  and  Course. — The  prognosis  in  pericarditis  varies  greatly  with 
the  individual  case.  The  purulent  cases  with  a  septic  temperature  curve 
are,  as  a  rule,  fatal;  a  small  percentage  may  recover  if  the  pericardial 
sac  is  opened  and  carefully  drained.  In  non-purulent  pericarditis  the 
prognosis,  so  far  as  life  is  concerned,  is  good,  but  in  most  of  these  cases 
the  heart  is  permanently  crippled  by  extensive  adhesions.  On  the  whole, 
therefore,  it  should  be  recognized  that  pericarditis  of  any  form  is  a  very 
serious  disease,  and  that,  while  complete  recovery  may  occur  in  a  few  of 
the  mild  cases,  it  is  not  to  be  expected.  From  the  standpoint  of  etiology 
the  pericarditis,  associated  with  acute  rheumatism  and  chorea,  has  a  much 
more  favorable  prognosis  than  that  produced  by  or  associated  with  other 
infections. 

The  duration  of  the  acute  symptoms  may  vary  from  one  week  in  the 
mild,  to  many  weeks  in  the  severe,  cases ;  in  the  average,  the  physical  signs 
run  their  course  in  about  three  weeks,  but  there  is  a  long  period  of  weeks, 
and  sometimes  months,  during  which  the  heart  makes  a  slow,  and  in  the 
majority  of  instances,  only  partial,  recovery. 

Treatment. — The  prophylactic  treatment  of  pericarditis  is  the  same 
as  that  of  endocarditis.  The  child  should  be  protected  from  rheumatism, 
and  second  attacks  of  this  disease  should  be  prevented  if  possible.  Diseased 
tonsils  and  adenoids  should  be  removed  in  all  children  who  have  suffered 
from  one  attack  of  rheumatism.  When  rheumatic  symptoms  occur,  the 
child  should  be  placed  in  bed,  the  disease  carefully  treated,  and  the  heart 
watched  for  evidence  of  acute  inflammation. 

Treatment  of  the  Attack. — Absolute  rest  in  bed  is  to  be  insisted 
upon  throughout  the  acute  symptoms;  the  patient  during  this  time  should 
do  nothing  for  himself  that  can  be  done  by  others.  Following  this,  "the 
rest-in-bed"  treatment,  somewhat  modified  to  suit  the  exigencies  of  the 
case,  should  be  continued  until  the  heart  has  sufficiently  recovered  its 
physiological  competency  to  permit  the  patient  to  get  out  of  bed  Avithout 
producing  symptoms  of  heart  strain.  His  diet  should  be  simple,  nutritious 
and  suited  to  his  digestive  capacity ;  milk,  eggs  and  cereals  are  to  be  recom- 
mended. If  rheumatism  be  present,  it  should  be  carefully  treated  as  noted 
in  the  chapter  on  that  disease.  The  antirheumatic  treatment,  however, 
should  not  be  given  after  the  acute  rheumatic  symptoms  have  disappeared, 
as  it  exercises  no  controlling  influence  over  the  inflammation  of  the  peri- 
cardium. An  ice-bag  should  be  applied  to  the  pericardial  region  and  kept 
there  the  greater  portion  of  the  time,  until  the  acute  symptoms  have  com- 
menced to  subside.  The  ice-bag  reduces  the  temperature,  quiets  the  action 
of  the  heart  and  probably  modifies  the  severity  of  the  pericardial  inflam- 
mation.   Blisters  and  counterirritants  over  the  region  of  the  heart  do  more 


CHROXIC    PERICARDITIS    WITH    ADHESIONS  513 

liarm  than  good.  In  chronic  pericarditis  1  drachm  of  tincture  of  iodin, 
mixed  with  1  ounce  of  anhydrous  lanolin,  may  be  used  as  an  inunction 
over  the  cardiac  region.  Iodin  given  in  this  form  is  rapidly  absorbed,  and 
may  possibly  have  some  influence  in  promoting  absorption.  Morphin  in 
from  1/10-  to  1/50-grain  doses  may  be  given  hypodermically  to  relieve 
pain ;  this  is  only  necessary  where  the  cardiac  distress  is  very  marked.  If 
bromid  of  soda  in  5-  or  10-grain  doses  relieves  the  nervous  irritability 
and  cardiac  distress,  it  may  be  used  instead  of  morphin.  Where  the  heart 
is  weak  and  myocardial  insufficiency  threatens,  strychnin,  digitalis  and  whis- 
key should  be  given.  The  digitalis,  especially  in  many  of  these  cases,  serves 
a  useful  purpose,  but  its  action  should  be  carefully  watched,  and  if  its 
administration  is  followed  by  an  improvement  in  the  action  of  the  heart, 
it  should  be  continued.  Whiskey  and  strychnin,  if  they  do  not  disturb 
the  stomach,  can  do  no  harm  and  may.  therefore,  be  given  for  days  at  a 
time,  where  cardiac  and  respiratory  stimulation  are  necessary. 

The  treatment  of  pericarditis  with  marked  effusion  calls  upon  the 
physician  to  decide  the  difficult  question  as  to  whether  an  attempt  shall 
be  made  to  remove  the  fluid  either  by  aspiration  or  by  radical  surgical  meas- 
ures. In  the  opinion  of  Rotch,  "Paracentesis  of  the  pericardium  should 
unhesitatingly  be  performed  when  life  is  in  danger  from  undue  distention 
of  the  pericardial  sac.  A  small  aspirating  trochar  should  be  used.  Opin- 
ions differ  widely  as  to  the  best  point  of  puncture.  Inasmuch  as  the 
heart,  when  an  effusion  is  present,  remains  in  its  usual  position  and  does 
not,  even  when  much  enlarged,  impinge  on  the  fifth  right  interspace,  and 
as  the  effusion,  even  when  in  so  small  an  amount  as  100  c.  c,  is  found  at 
that  point,  I  consider  it  more  rational  to  choose  the  fifth  right  interspace, 
•4  cm.  (li/>  inches)  outside  the  right  border  of  the  sternum,  as  the  point 
for  tapping,  thus  avoiding  all  danger  of  injuring  the  heart.  At  this  point 
the  right  internal  mammary  artery  will  not  be  injured.  Another  place  to 
aspirate,  recommended  by  Osier,  is  the  left  fourth  interspace,  either  close 
to  the  sternal  margin  or  2.5  cm.  (1  inch)  from  it,  in  order  to  avoid 
wounding  the  internal  mammary  artery.  The  left  fifth  interspace,  3.75 
cm.  (li/>  inches)  from  the  sternal  border,  may  also  be  taken  for  the  point 
of  puncture."  After  introducing  the  needle  as  above  directed,  such  fluid 
as  will  readily  flow  through  the  trochar  should  be  allowed  to  drain  away 
very  slowly.  And  if  this  operation  reveals  a  purulent  pericarditis,  the  case 
should  be  referred  to  the  surgeon  for  operative  treatment,  since  these 
cases  are  practically  hopeless  under  any  other  mode  of  treatment.  In 
properly  selected  cases.  es}>ecially  in  older  children,  exsection  of  the  rib, 
and  the  opening  and  free  drainage  of  the  pericardial  sac,  gives  to  the 
patient  almost  the  only  chance  he  has  for  recovery. 

CHRONIC    PERICARDITIS   WITH  ADHESIONS 

This  condition  is  commonly  caused  by  rheumatism  or  tuberculosis.  In 
rare  instances  there  is  no  history  of  an  acute  attack,  the  disease  being  in- 


514  PERICARDITIS 

sidious  in  its  onset.  Nearly  all  cases  follow  acute  pericarditis;  in  the 
great  majority  pericardial  adhesions  are  left,  which  permanently  cripple 
the  heart.  The  pericardium  is  thickened  and  its  visceral  and  parietal 
layers  are  adherent,  completely  or  partially  obliterating  the  pericardial 
sac.  Adhesions  may  also  bind  it  to  the  diaphragm,  pleura,  or  chest  wall. 
A  low  grade  of  chronic  myocarditis  usually  follows,  resulting  in  increasing 
dilatation  and  increasing  weakness  of  the  cardiac  muscle,  and  finally  re- 
sulting in  death  from  cardiac  insufficiency.  In  other  instances,  especially 
in  those  cases  of  rheumatic  origin,  the  cardiac  muscle,  forced  to  do  ex- 
traordinary work,  because  of  pericardial  adhesions,  becomes  greatly  hyper- 
trophied.  These  cases  may  live  for  many  years  under  proper  medical 
supervision. 

Symptomatology. — The  symptoms,  as  a  rule,  are  those  of  gradually  in- 
creasing myocardial  insufficiency;  the  pulse  is  rapid,  weak,  and  irregular, 
easily  influenced  by  slight  exertion.  Cardiac  pain  and  dyspnea  are  usually 
developed  by  exercise;  sudden  death  from  cardiac  insufficiency  may  occur 
at  any  time.  In  other  instances  there  is  slow  failure  of  the  cardiac  muscle, 
lasting  over  months  or  years. 

The  most  characteristic  physical  sign  is  a  retraction  of  the  chest  wall, 
especially  noticeable  over  the  lower  cardiac  area,  occurring  with  every 
systole.  Immobility  of  the  heart  is  *a  valuable  sign ;  the  position  of  the 
apex  does  not  move  with  a  change  in  the  position  of  the  child.  There  is 
an  exaggerated  diastolic  shock  accompanying  the  second  sound  over  the 
greater  part  of  the  pericardium  (Broadbent).  Friction  sounds  may  be 
heard,  but,  as  a  rule,  are  not  present.  The  area  of  cardiac  dullness  is 
greatly  increased  and  X-ray  pictures  show  great  increase  in  the  size  of  the 
heart,  and  may  show  adhesions.  The  valve  sounds,  which  may  be  present 
in  these  cases,  may  be  due  to  chronic  endocarditis  or  -to  dilatation,  with  a 
resulting  valvular  insufficiency;  when  present  they  confuse  rather  than 
assist  in  the  diagnosis  of  adherent  pericardium.  Pericarditic  pseudo- 
cirrhosis  of  the  liver  may  occur  (Pick's  disease). 

Biag^osis. — The  diagnosis  is  very  difficult  if  the  characteristic  sign  of 
SA'stolic  chest  retraction  is  not  present;  the  diagnosis,  however,  may  oft- 
times  be  inferred  if  the  physician  was  fortunate  enough  to  have  seen  and 
made  the  diagnosis  of  the  acute  pericarditis,  which  was  afterward  followed 
by  the  symptoms  of  myocardial  insufficiency  above  noted. 

Treatment. — The  treatment  of  this  condition  is  the  same  as  that  of  the 
myocardial  insufficiency,  which  occurs  in  chronic  valvular  lesions. 


SECTION   IX 
DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS 

CHAPTER    LX 

THE    BLOOD 

Red  Blood  Corpuscles  (Erythrocytes). — Xormal  adult  blood  contains 
5,000,000  red  blood  corpuscles,  7,500  white  blood  corpuscles,  and  200,000 
blood  plates  to  the  cubic  millimeter.  Erythrocytes  (red  blood  corpuscles) 
are  the  hemoglobin  carriers,  and  the  potency  of  their  most  important  func- 
tion, that  of  bearing  oxygen  from  the  lungs  to  the  tissues,  depends  upon 
the  amount  of  hemoglobin  they  contain.  Hemoglobin  is  therefore  the 
most  important  constituent  of  the  blood.  The  specific  gravity  of  the  blood 
varies  directly  with  the  amount  of  hemoglobin  it  contains.  The  normal 
ERYTHROCYTE  ( NORMOCYTE)  lias  no  nucleus  and  varies  in  size  from  6  to 
9  pi.  Larger  and  smaller  forms  are  frequently  met  with.  The  small  red 
blood  corpuscles  are  known  as  microcytes ;  they  may  be  less  than  half  the 
size  of  the  normocyte,  varying  from  5  to  3  /^.  The  large  red  blood  cor- 
puscles are  called  macrocytes  (9  to  12  fi),  megalocytes  (12  to  16/<),  and 
gigantocytes  (16  to  20  ^).  All  the  above  forms  of  red  blood  corpuscles  are 
non-nucleated  and  may  appear  normally  in  the  blood  of  very  young  infants. 
The  very  large  and  very  small  forms  are  pathological,  except  during  the 
early  days  of  life.  They  may  be  present  in  considerable  numbers  in  all 
forms  of  anemia,  but  they  have  not  the  pathological  significance  of  the 
xucLEATED  FORMS  (erythroblasts)  .  The  following  varieties  of  ery- 
throblasts  occur:  Normoblasts  are  nucleated  red  blood  corpuscles  of  nor- 
mal size.  They  are  the  immediate  antecedents  of  normal  red  corpuscles, 
and  occur  normally  in  the  blood  of  the  embrj'o  in  large  numbers;  a  few 
may  be  found  during  the  first  few  days  after  birth,  but  soon  disappear. 
Each  normoblast  contains  a  round,  sometimes  irregular,  darkly  staining 
nucleus,  one-half  the  diameter  of  the  cell.  They  are  found  in  all  forms 
of  severe  anemia,  both  primary  and  secondary.  Megaloblasts  (giganto- 
hJasts)  are  red  blood  cells  two  or  three  times  the  normal  size,  containing 
a  large,  round,  or  irregularly  shaped  nucleus.  The  c}i;oplasm  is  frequently 
polychromatophilic,  and  those  cells  of  irregular  shape  are  called  poikilo- 
hlasts;  the  presence  of  these  corpuscles,  especially  in  large  numbers,  indi- 

515 


516  THE   BLOOD 

cates  a  severe  type  of  anemia.  Microhlasts  are  red  blood  corpuscles  often 
less  than  half  the  normal  size,  containing  a  small,  deeply  staining  nucleus. 
They  are  seen  in  primary  and  in  severe  types  of  secondary  anemia. 

Poikilocytosis  is  the  term  used  for  the  distorted  and  irregularly  shaped 
and  sized  red  blood  corpuscles;  they  occur  in  various  types  of  anemia, 
especially  the  grave  primary  forms.  In  the  more  severe  types  these  ill- 
shaped  irregular  forms  are  present  in  great  numbers.  By  anisocytosis  is 
meant  a  variability  in  size  of  the  red  corpuscles  in  a  given  specimen. 
Oligocythemia,  or  a  scarcity  of  red  corpuscles,  is  most  marked  in  per- 
nicious anemia  and  in  the  anemias  of  infancy  and  early  childhood.  Poly- 
cythemia, an  increased  number  of  red  corpuscles  per  cubic  millimeter, 
occurs  frequently  in  the  anemias  of  infancy  and  early  childhood,  especially 
of  the  chlorotic  type,  and  also  as  a  clinical  entity  in  later  life.  In  poly- 
chromasia,  or  polychromatophilia,  the  red  cells  show  a  varying  affinity  for 
basic  dyes  in  addition  to  their  normal  reaction  to  acid  dyes ;  this  may  occur 
in  any  form  of  the  primary  and  secondary  anemias,  but  is  not  marked  in 
chlorosis.  Oligochromemia,  or  a  scarcity  of  hemoglobin  per  unit  volume 
of  the  blood,  is  still  more  characteristic  of  the  anemias  of  childhood  than 
of  adult  life.  The  color  index  of  the  blood  refers  to  the  total  amount  of 
hemoglobin  as  related  to  the  number  of  red  cells.  It  is  determined  by 
dividing  the  per  cent,  of  hemoglobin  by  the  per  cent,  of  red  blood  cells. 
The  normal  per  cent,  of  hemoglobin  in  infancy  is  58  to  78,  and  the  normal 
per  cent,  of  red  blood  cells  is  100 ;  the  color  index  of  the  normal  infant  is 
therefore  70  divided  by  100,  or  0.70.  In  anemic  conditions  in  infancy  the 
normal  low  color  index  is  still  further  reduced;  that  is  to  say,  the  anemia 
tends  toward  the  chlorotic  type,  in  which  there  is  a  greater  reduction  of 
hemoglobin  than  of  red  blood  corpuscles. 

White  Blood  Corpuscles.  {Leukocytes) . — \Miite  blood  corpuscles  are 
represented  by  the  following  varieties:  Small  lymphocytes  (small  mono- 
nuclear leukocytes)  are  about  the  size  of  a  red  blood  corpuscle,  consisting 
of  a  large  nucleus,  surrounded  by  a  narrow  rim  of  cytoplasm.  They  are 
the  predominating  form  in  infancy  and  early  childhood.  During  the 
first  year  of  life  they  represent  from  53  to  55  per  cent,  of  all  leukocytes, 
while  in  the  adult  they  represent  only  about  24  per  cent.  There  is  a  grad- 
ual diminution  in  the  percentage  of  small  lymphocytes  throughout  child- 
hood. They  are  formed  in  the  spleen,  lymph  nodes,  and  other  lymphatic 
tissues.  The  small  lymphocytes  are  notably  increased  in  whooping-cough, 
measles,  in  severe  forms  of  anemia,  in  the  status  lymphaticus,  and  in  all 
conditions  in  which  there  is  a  hyperplasia  of  the  spleen  and  other  lymphatic 
tissues.  They  are  enormously  increased  in  the  lymphatic  form  of  leukemia. 
Large  lymphocytes  are  two  or  more  times  the  size  of  the  small  lymphocytes, 
and  contain  a  large  oval  nucleus  surrounded  by  a  narrow  rim  of  cytoplasm. 
The  large  mononuclear  leukocytes  (splenocytes)  are  two  or  three  times  the 
size  of  red  corpuscles  and  contain  a  large  single  nucleus  in  a  large  amount 
of  nongranular  or  faintly  granular  cytoplasm.  The  nucleus  is  frequently 
irregular,  and  when  it  shows  a  marked  indentation  the  cell  is  called  a 


WHITE    BLOOD    CORPUSCLES  517 

"transitional  cell."  These  cells  represent  from  3  to  6  per  cent,  of  the  total 
number  of  leukocytes,  although  they  are  frequently  much  more  numerous 
in  infancy  and  early  childhood.  They  are  formed  chiefly  in  the  spleen. 
Polymorphonuclear  neutrophiles  are  about  13  yu  in  diameter,  a  little  less 
than  twice  the  size  of  the  red  blood  corpuscle.  They  each  contain  a 
chromatin-rich  nucleus  which  is  polymorphous,  and  may  resemble  the 
letters  E,  V,  S,  U  and  Z,  or  show  wreathed  or  rosette  forms.  This  nucleus 
is  surrounded  by  a  neutrophilic  granular  cytoplasm.  In  infancy  they  rep- 
resent 35  per  cent,  of  the  total  number  of  leukocytes,  and  gradually  in- 
crease in  percentage  throughout  childhood  to  from  60  to  70  per  cent,  in 
the  adult.  They  are  produced,  as  are  other  granular  cells,  by  the  bone  mar- 
row, and  descend  directly  from  the  neutrophilic  myelocytes.  They  are  in- 
creased in  diphtheria,  pneumonia,  scarlet  fever,  smallpox,  meningitis  (the 
tuberculous  form  excepted),  rheumatism,  and  especially  in  all  septic  cases 
such  as  septicopyemia,  septicemia,  appendicitis,  peritonitis,  septic  arthritis 
and  acute  inflammatory  processes  of  all  kinds ;  they  are  also  found  in  great 
excess  in  myelogenous  leukemia.  Eosinopliiles  are  generally  slightly  larger 
than  the  neutrophiles  above  described ;  the  nuclei  are  usually  bi-lobed,  fre- 
quently tri-lobed  and  polymorphous;  they  differ  from  the  neutrophiles  also 
in  having  large  refractive  granules,  which  stain  with  acid  dyes,  such  as 
eosin.  They  are  formed  by  the  eosinophile  myelocytes  in  the  bone  marrow. 
In  infancy  they  represent  only  1  or  2  per  cent.,  and  in  adults  1  to  4  per 
cent.,  of  the  total  number  of  leukocytes.  They  are  increased  by  diseases 
due  to  animal  parasites,  such  as  trichiniasis  and  uncinariasis,  in  chronic 
skin  diseases,  leukemia  and  other  diseases  of  the  bone  marrow,  postfebrile 
conditions,  and  in  bronchial  asthma.  BasopJiiles,  or  mast  cells,  are  gran- 
ular cells  slightly  smaller  than  the  neutrophiles,  having  a  somewhat  ir- 
regular, frequently  knotted  or  tri-lobed  nucleus;  the  granules,  generally 
large,  stain  only  with  basic  dyes.  They  are  very  scanty  in  normal  blood, 
and  a  proportion  of  1  per  cent,  or  over  is  pathological.  They  are  of  diag- 
nostic value  in  myelogenous  leukemia,  where  they  are  greatly  increased. 

Blood  platelets  are  small,  probably  non-nucleated  forms,  believed  by  some 
to  be  related  to  the  white  blood  corpuscles,  by  others  to  the  red  corpuscles. 
They  arc  of  irregular  shape,  from  2  to  3  /^  in  diameter,  and  their  average 
number  is  from  200,000  to  300,000  to  the  cubic  millimeter,  according  to 
various  observers.  In  pathological  conditions  their  number  may  be  less 
than  100.000  or  more  than  300,000.  Further  than  that  they  are  concerned 
in  the  formation  of  fibrin  and  in  the  clotting  of  blood,  their  physiological 
significance  is  not  known.  They  are  increased  in  posthemorrhagic  and  sec- 
ondary anemias,  pneumonia  and  tuberculosis,  and  especially  in  myelogenous 
leukemia.  They  are  decreased  in  lymphatic  leukemia,  pernicious  anemia, 
hemophilia,  and  in  some  forms  of  purpura. 

Pathological  White  Corpuscles. — Myelocytes  (marrow  cells)  are 
usually  larger  than  the  polymorphonuclears,  but  they  may  vary  in  size. 
They  contain  one  large  oval  nucleus,  surroimded  by  a  rim  of  protoplasm 
containing  granules,  either  neutrophilic  or  acidophilic.     This  cell  occurs 


518  THE   BLOOD 

very  rarely  in  the  blood  of  the  new-born,  and  otherwise  is  found  in  the 
peripheral  blood  only  in  pathological  conditions.  It  represents  the  imma- 
ture (polymorphonuclear)  leukocyte  which  has  been  hurried  out  from 
the  bone  marrow  before  its  completion.  Three  varieties  may  occur: 
neutrophilic  myelocytes,  the  granules  of  which  stain  with  neutral  dyes; 
eosinophilic  myelocytes,  the  granules  staining  a  brilliant  red  with  eosin; 
basophilic  myelocytes,  the  granules  of  which  stain  only  with  basic  dyes. 
Myelocytes  may  be  found  in  infancy  in  all  conditions  in  which  there  is  a 
marked  leukocytosis.  They  are  always  present  in  large  numbers  and  are 
of  special  diagnostic  importance  in  myelogenous  leukemia,  and  also  in 
disease  of  the  bone  marrow  and  other  blood-forming  structures. 

Peculiarities  of  the  Blood  in  Infancy  and  Childhood. — The  blood  of 
infants  differs  materially  from  that  of  adults.  It  is  an  immature  tissue, 
which  gradually  approaches  the  adult  type.  The  morphological  changes 
which  take  place  in  the  blood  throughout  infancy  and  childhood  are  clearly 
portrayed  in  the  accompanying  tables.  In  fetal  life  both  red  and  white 
blood  corpuscles  are  produced  by  the  same  blood-forming  organs,  the  liver, 
bone  marrow,  spleen,  thymus  and  lymphatic  tissues  in  general ;  but  toward 
the  end  of  embryonic  life  the  liver,  under  normal  conditions,  loses  this 
function,  but  still  continues  for  a  time  to  hold  a  reserve  supply  of  iron, 
from  which  hemoglobin  is  made  during  the  early  days  of  postnatal  life. 
After  birth  the  marrow,  spleen  and  lymphatic  tissues  continue  to  be  the 
important  blood-forming  organs,  and  nature  then  makes  the  attempt  to 
differentiate  the  special  work  of  these  organs,  so  that  the  red  blood  cor- 
puscles and  granular  leukocytes  (polynuclear  neutrophiles,  mast  cells, 
eosinophils  and  myelocytes)  may  have  their  origin  exclusively  in  the  bone 
marrow,  and  the  lymphocytes  exclusively  in  the  spleen,  lymph  glands  and 
other  lymphatic  tissues.  This  differentiation  is  almost  perfectly  established 
in  the  adult,  but  in  the  infant,  under  certain  abnormal  conditions,  when 
there  is  a  great  demand  made  upon  these  blood-forming  organs  for  either 
the  production  of  red  or  white  cells,  there  may  be  a  return  to  the  fetal 
conditions,  in  which  both  red  and  white  cells  are  produced  in  all  of  the 
blood-forming  organs.  In  the  more  severe  forms  of  anemia  the  liver  itself 
becomes  enlarged  and  again  assists  in  the  blood-forming  process.  The 
greatest  portion  of  this  extra  work  falls,  however,  upon  the  spleen  and 
lymphatic  glands.  These  organs,  especially  the  spleen,  become  greatly  en- 
larged by  a  true  hyperplasia,  which  occurs  in  response  to  the  demand  for 
this  increase  of  function.  This  reversion  of  function  is  an  explanation 
of  the  fact  that  in  the  anemias  of  infancy  and  young  childhood  there  is 
a  tendency  on  the  part  of  the  blood  to  revert  to  the  infantile  type;  that 
is  to  say,  the  red  blood  corpuscles  vary  greatly  in  size,  shape,  and  staining 
reaction,  and  nucleated  forms  are  present.  The  blood  in  infancy,  being  in 
a  formative  stage,  is  much  more  vulnerable,  and  very  great  changes  may 
be  produced  in  it  from  comparatively  slight  causes.  The  blood-forming 
organs  at  this  period  are  taxed  to  their  full  capacity  under  normal  condi- 
tions, so  that  when  any  unusual  call  is  made  upon  them,  as  in  the  severe 


THE    BLOOD    IN    INFANCY    AND  CHILDHOOD  519 

anemias  of  childhood,  they  are  unable  to  meet  the  increased  demands.  This 
susceptibility  of  the  blood  to  injury,  and  this  lack  of  reserve  power  in  the 
blood-forming  organs,  are  the  reasons  why  infants  bear  hemorrhage  badly, 
and  wh}^  such  pronounced  anemias  develop  from  comparatively  slight 
causes. 

The  marked  deficiency  of  the  blood-forming  organs  of  the  infant,  and 
their  lack  of  reserve  power  in  the  production  of  red  blood  corpuscles,  do 
not  hold  true  for  white  blood  corpuscles.  In  infancy  there  is  a  normal 
leukocytosis,  the  variations  and  the  special  characteristics  of  which,  through- 
out infancy  and  childhood,  are  detailed  in  the  following  tables.  This  leuko- 
cytosis is  very  readily  increased  by  slight  causes  in  the  infant,  so  that  little 
pathological  significance  attaches  to  a  count  imder  20,000  in  a  child  less 
than  four  years  of  age.  After  the  sixth  year  the  leukocyte  picture  ap- 
proaches closely  to  the  adult  type,  and  counts  made  after  this  time  of  life 
have  almost  the  same  interpretation  that  they  have  in  the  adult.  In  the 
comparative  study  of  the  leukocyte  blood  pictures  of  the  child  and  adult, 
it  is  important  to  remember  that  up  to  the  sixth  year  of  life  the  mono- 
nuclear cells  or  lymphocytes  are  relatively  and  actually  greatly  increased 
in  numbers,  and,  since  these  cells  are  produced  by  the  spleen,  lymph  glands, 
and  other  lymphatic  tissues,  their  presence  in  increased  numbers  indicates 
an  excessive  activity  of  lymphatic  tissues  during  this  period  of  life.  This 
accounts  for  the  prevalence  of  lymphatic  diseases  in  infancy  and  child- 
hood, and  also  explains  why  the  leukoc3^tosis  which  occurs  in  the  well- 
marked  anemias  of  childhood  as  a  result  of  disease  or  overwork  of  the 
blood-forming  organs  is  commonly  oi  the  lymphocytic  type.  Digestive 
leukocytosis,  however,  which  is  very  marked  in  infancy,  and  leukocytosis 
produced  by  general  sepsis,  are  in  the  child,  as  in  the  adult,  of  the  poly- 
morphonuclear type. 

The  hemoglobin  changes  which  occur  in  the  blood  of  the  infant  and 
which  are  clearly  portrayed  in  the  following  tables  are  of  great  physiological 
and  pathological  importance.  The  high  percentage  of  hemoglobin  which 
occurs  at  birth  and  which  continues  for  a  number  of  days  is  the  continua- 
tion of  the  fetal  condition,  kept  up  by  drawing  upon  the  store  of  iron 
which  the  liver  contains  at  this  time.  There  is  a  sharp  fall  in  hemoglobin 
about  the  third  week  of  life,  which  is  due  partly  to  the  exhaustion  of  the 
fetal  supply  of  iron  and  partly  to  the  dilution  of  the  blood,  which  results 
from  the  large  quantity  of  fluid  taken  by  the  infant.  From  this  time  on 
throughout  childhood  there  is  a  slow  increase  in  the  amount  of  hemoglobin, 
but  it  does  not  approach  the  normal  until  the  tenth  year  of  life.  During 
all  of  this  time  the  child  has  a  normal  red  cell  count,  so  that  each  red 
corpuscle  must  be  deficient  in  hemoglobin.  In  other  words,  there  is  a  nor- 
mal chlorotic  condition,  or  low  color  index,  which  continues  throughout 
early  childhood.  In  all  diseases  which  affect  the  blood  or  blood-forming 
organs,  producing  anemia,  the  hemoglobin  suffers  -first  and  the  chlorotic 
condition  is  increased.  Tliis  is  one  of  the  marked  characteristics  of  the 
anemias  of  childhood. 


520 


THE  BLOOD 


o     o 

o     o 

1 

< 

§So 

>o  „oo 
00  °o> 

B 

o 

C3 

_  o 

03« 

C   >> 

2>i 

|2o- 

■<ir     in 

.2  8 

85§ 

O   -CI 

a 
o 

a 

^ 

^ 

_  v 

1^ 

.2  8 
i'J2 

§5§ 

C3  o© 
00  °05 

o 

a 
o 
a 

® 

lO" 

§1 

i 

1:1 

■ai 

*^    1 

§ 

a 

lo 

> 

a 
a 

_>> 

03 

J2 

-1 

> 

II 
'c 

si 

S 

s 

o 

^ 

o 

115  O© 

3 

lO-MO 

o 

3 

2Q^ 

>o 

0) 

•g 

o 

i 
5      • 

si 

8 

8 

o 
a 

JS 

o 

t 

^& 

o 

in 

00 

CJ 

g" 

00 

"^ 

•c 

»Ci 

^ 

n 

« 

OO 

3 

i  I 

1> 

1 

CO  ^^ 

00  005 

■3-9 

0 

1*1 

03 

(N 

t>r    00 

■fl 

ai 

^ 

u 

.? 

m 

1 

So2 

Soo 

si 

m  3 

<j 

CO* 

3 

£ 

■^ 

i 

3 

te 

t3 

"S 

13 

a 

^ 

|2 

PM 

> 

a 

m 

_g 

CJ 

.2 

.2 

tea 

13 

-B 

si 

FQ     g 

Q, 

a 

a  o 

o 

fl 

5 

»     3 

d 

a 

3 

ja 

CO 

i 

'.B'i 

a 

o 
CJ 

S 

THE    BLOOD    TX    IXFAXCY  AXD   CHILDHOOD 


521 


o 

3 

< 

'•'5*' 2 

s 

^ 

i 

d 

2 

d 

c 

2^ 

:? 

'" 

;s. 

1 
d 

„ 

o 

00  u 

o      ^ 

o 
1 

in 

•n 

S  5  3 

i 

■-^ 

S. 

o 

s 

oS 

o 

T3>i 

S5 

S 

eJ 

K^ 

c 

"s 

J3 

3| 

lO 

o 

d 

c 
o 

1 

8 

o 

5^ 

ioi 

o 
1 

f-Q 

o      2" 

» 

ji 

S5 

^ 

«5 

§■"§" 

00 

o 

W 

PQ 

1 

I 

^ 

■< 

"^ 

ao 

fi  u 

£ 

o  2 

9 

"o  ^ 

E 

1 

il 

00 

s 

1                  ? 

i 

•n 

OQ 

— 

OD 

c 

U 

S:      -3 

-             O 

3        5S 

3 

11 

___  >» 

.,   >> 

c      a 

a 
o 

s- 

g 

o 

& 
o 

2 

1  2 

I"! 

B 

0-1  2 

1 
1 

1 

^ 

1 

It  will  thus  be  seen  that  the  blood  picture  in  the  anemias  of  infancy 
and  early  childhood  cannot  be  interpreted  by  adult  standards.  These 
pictures  may  closely  resemble  pernicious  anemia  and  leukemia  in  the  adult 
and  yet  be  due  to  causes  that  yield  more  or  less  promptly  to  treatment. 
The  above  tables  will  assist  materially  in  the  interpretation  of  blood  pic- 
tures at  different  ages.  The  following  blood  changes  are  more  or  less 
characteristic  of  the  anemias  of  infancy  and  young  childhood.  First,  a 
marked  deficiency  of  hemoglobin  without  a  corresponding  decrease  in  the 
number  of  red  blood  corpuscles.  Indeed  frequently  with  an  increased  num- 
ber of  red  corpuscles ;  this  produces  a  low  color  index,  or  so-called  chlorotic 
condition  of  the  blood.  Second,  great  variations  in  the  size,  shape  and 
stainino-   reaction    of  red   blood   corpuscles,    and   the   presence   of  many 


522  SIMPLE   SECOND AEY  ANEMIA 

nucleated  forms.     Third,  a  leukocytosis,  mild  or  severe,  the  nongranular 
cells  or  lymphocytes  often  predominating. 

Enlargement  of  the  spleen  and  other  lymphatic  tissues  is  very  com- 
monly associated  with  the  secondar}'  anemias  of  infancy.  This  association 
of  splenomegaly  and  secondary  anemia  has  been  very  generally  utilized  in 
the  classification  of  these  anemias. 


CHAPTER    LXI 
SIMPLE    SECONDARY    ANEMIA 

The  simple  secondary  anemias  are  so  called  because  they  are  sec- 
ondary to  some  clearly  defined  disease  or  condition  which  causes  destruc- 
tion of  or  interferes  with  the  formation  of  hemoglobin  and  red  blood  cor- 
puscles. They  are  thereby  distinguished  from  the  primary  and  pernicious 
anemias,  the  causes  of  which  are  unknown,  whose  well-defined  blood  pic- 
ture is,  in  the  present  state  of  our  knowledge,  considered  to  be  due  to  some 
pathological  factor  which  acts  on  the  blood-forming  organs.  The  blood  pic- 
tures, however,  presented  by  the  secondary  anemias  of  infancy  and  child- 
hood are  not  so  clearly  differentiated  from  the  primary  anemias  as  they 
are  in  adult  life.  The  embryonic  type  of  blood  contains  a  number  of 
varieties  of  corpuscles  which  are  considered  more  or  less  characteristic  of 
the  primary  anemias  of  adult  life,  but  which  do  not  occur  in  the  secondary 
anemias  of  the  adult;  while,  on  the  other  hand,  in  the  secondary  anemias 
of  infancy  and  young  childhood  there  is  a  tendency  on  the  part  of  the  cor- 
puscles to  revert  to  the  embryonic  type.  For  this  reason  they  may  present 
a  blood  picture  containing  the  various  varieties  of  nucleated  red  blood  cor- 
puscles and  also  red  corpuscles  varving  greatly  in  their  size,  shape,  and 
staining  qualities,  thus  presenting  a  picture  which  may  possibly  be  con- 
fused with  the  primary  anemias.  In  addition  to  this,  it  is  believed  that 
the  primary  or  pernicious  anemias  of  early  life  may  sometimes  begin  as 
simple  anemias. 

Etiology. — Simple  anemia  may  be  hereditary,  the  infant  being  born 
anemic  and  inheriting  from  diseased  parents  weak  or  defective  blood- 
forming  organs,  which  are  unable  to  meet  the  demands  of  the  rapidly 
growing  body.  Chronic  intestinal  toxemia  and  diseases  of  the  gastro- 
intestinal canal  are  the  most  common  causes  of  this  condition  in  infancy. 
Chronic  glandular  tuberculosis  is  one  of  the  most  common  causes  of  anemia 
in  childhood,  and  where  other  causes  are  not  apparent  this  condition  is 
to  be  suspected.  Among  the  other  common  anemia  producers  are  non- 
tuberculous  adenitis,  rheumatism,  malaria,  syphilis,  contagious  diseases 
such  as  influenza  and  diphtheria,  malignant  disease,  status  lymphaticus, 
prolonged  suppuration,  chronic  nephritis,  intestinal  parasites,  loss  of  blood 
from  hemorrhage,  bad  air,  lack  of  sunshine  and  poor  food.     These  latter 


DIAGNOSIS  523 

causes  are  potent  factors  in  producing  anemia  among  the  poor  of  our  large 
cities. 

Symptomatology.— General  Symptoms. — That  the  child  is  anemic  is 
first  made  evident  by  the  facts  that  the  skin  is  pale,  transparent  or  per- 
haps sallow,  and  that  the  mucous  membranes  gradually  lose  their  color. 
The  blanching  of  the  skin  and  mucous  membranes  will  vary  with  the  po- 
tency of  the  underlying  cause.  In  severe  cases,  especially  in  infancy,  the 
skin  may  become  edematous.  The  child  lacks  energy,  is  listless,  has  no 
appetite,  and,  as  a  rule,  suffers  from  constipation  and  digestive  disturb- 
ances. There  is  a  gradual  failure  in  health,  the  child  losing  in  weight  and 
strength.  It  has  little  endurance,  is  easily  fatigued  and  suffers  from  short- 
ness of  breath  on  exercising.  Nervous  symptoms  are  always  present;  the 
child  becomes  irritable,  sleepless,  hysterical,  frequently  suffers  from  night 
terrors,  headache,  habit  spasms,  incontinence  of  urine,  chorea,  and  other 
neuroses.  In  a  large  percentage  of  these  cases  the  physician's  attention 
is  directed  to  the  anemia  in  trying  to  discover  the  cause  of  a  recently  de- 
veloped nervous  syndrome. 

In  pronounced  cases  of  anemia  the  heart  -is  weak,  rapid,  irregular,  and 
may  be  dilated.  Hemic  murmurs  may  frequently  be  heard  over  the  base 
of  the  heart,  and  not  uncommonly  these  murmurs,  which  are  very  distinct 
with  the  child  lying  upon  its  back,  disappear  when  the  upright  position  is 
assumed.  The  peripheral  circulation  is  poor,  the  child  is  easily  chilled, 
suffers  from  cold  hands  and  feet.  Slight  enlargement  of  the  spleen  may 
be  present  without  special  pathological  significance.  The  liver  is  also 
frequently  increased  in  size. 

Blood  Examination. — From  the  above  symptom  group  the  diagnosis 
of  anemia  may  be  easily  made,  but  the  character  and  extent  of  the  anemia 
must  be  determined  by  a  blood  examination.  In  interpreting  the  blood 
picture  presented,  the  normal  low  hemoglobin  percentage  of  infancy  and 
early  childhood  must  be  kept  in  mind.  There  is  an  increased  reduction  of 
hemoglobin,  and  frequently  a  marked  decrease  in  the  number  of  red  blood 
corpuscles,  though  in  some  cases  the  count  may  be  nearly  normal.  The 
color  index  is  low;  that  is  to  say,  there  is  a  proportionately  greater  de- 
crease in  hemoglobin  than  in  red  blood  corpuscles,  so  that  the  anemia  is 
mildly  chlorotic  in  type.  In  severe  cases  the  hemoglobin  may  be  reduced 
to  25  or  30  per  cent.,  and  the  red  blood  corpuscles  may  show  a  count  of 
4,000,000  to  5,000,000  or  over,  but  in  the  very  severe  cases  there  is  a  great 
decrease,  sometimes  to  1,500,000.  Irregularities  in  the  shape  and  size  of 
red  blood  corpuscles  also  occur,  and  nucleated  forms  are  present.  These 
are  chiefly  normoblasts,  but  in  severe  forms  microblasts  and  megaloblasts 
may  also  occur.  Leukocytosis  frequently  is  present;  this  is  commonly  due 
to  an  increase  in  the  lymphocytes,  especially  in  gastrointestinal  conditions ; 
an  increase  in  polymorphonuclears  generally  denotes  some  complication. 
If  intestinal  parasites  be  the  cause  of  anemia,  eosinophilia  is  marked. 

Diagnosis. — In  the  vast  majority  of  cases  the  diagnosis  of  secondary 
anemia  can  be  made  in  the  child,  as  in  the  adult,  by  the  blood  picture 


524  PSEUDOLEUKEMIA    OF    IXFANTS 

alone.  It  is  only  in  the  very  severe  types  where  megaloblasts  occur  and 
polychromasia  exists  that  the  diagnosis  may  be  in  doubt,  but  even  in  these 
conditions  the  presence  of  an  exciting  cause,  the  great  preponderance  of 
normoblasts  as  compared  with  the  megaloblasts,  and  the  low  color  index 
should  be  sufficient  to  exclude  pernicious  anemia,  a  very  rare  disease  in 
childhood. 

In  those  cases  associated  with  enlarged  spleen  and  marked  leukocy- 
tosis there  may  be  great  difficulty  in  deciding  when  the  condition  ceases 
to  be  a  simple,  secondary  anemia,  and  becomes  the  pseudoleukemia  of  in- 
fancy (von  Jaksch's  disease).  In  this  differentiation  the  blood  picture 
of  the  latter  disease  will  be  of  assistance. 

Prognosis. — The  prognosis,  in  the  vast  majority  of  cases,  is  good, 
since  the  secondary  anemias  of  infancy  and  childhood,  as  a  rule,  depend 
upon  removable  causes. 

Treatment. — Since  secondary  anemia  is  a  symptom  of  some  other 
disease,  or  is  produced  by  remedial  causes,  the  object  of  the  physician 
should  be  to  search  carefully  for  the  underlying  causes  and  remove  them. 
Fresh  air,  sunshine,  good  food,  proper  hygienic  surroundings  are  impor- 
tant whatever  may  be  the  causative  factor.  Arsenic  and  cod-liver  oil  are 
valuable  adjuncts  in  the  treatment  of  almost  all  forms  of  anemia,  and  some 
easily  assimilated  form  of  iron  is  especially  indicated,  as  it  furnishes  the 
material  from  which  the  blood-forming  organs  manufacture  hemoglobin. 
Constipation  and  all  abnormal  conditions  of  the  gastrointestinal  canal 
must  be  carefully  treated,  and  the  child  fed  at  regular  intervals  on  a 
wholesome  food  suited  to  its  digestive  capacity. 


CHAPTER    LXII 

PSEUDOLEUKEMIA    OF    INFANTS 
{Von  Jaksch's  Disease) 

Under  this  term  von  Jaksch  in  1889  described  a  rather  clearly  defined 
symptom  group,  characterized  by  the  blood  picture  of  grave  secondary 
anemia,  with  leukocytosis,  enlargement  of  the  liver,  spleen,  and  sometimes 
other  lymphoid  tissues.  He  believed  this  condition  to  be  a  distinct  clinical 
entity,  but  the  trend  of  opinion  at  the  present  time  is  that  the  cases 
grouped  under  this  term  are  severe  secondary  anemias  associated  with 
enlarged  spleen,  occurring  almost  exclusively  in  infancy,  and  that  age  is 
largely  the  determining  factor  in  the  production  of  this  type  of  anemia. 
The  enlarged  spleen,  which  is  one  of  its  distinguishing  characteristics, 
is  but  one  of  the  manifestations  of  the  underlying  pathological  process, 
which  is  probably  toxic  in  character.  It  is  not  to  be  considered  as  a  causa- 
tive factor. 

Etiology. — Age  is  the  all-important  predisposing  factor.     The  great 


PLATE  VI. 


K  V 


.    I     cc  3t   ,^ 


I!  Ill  11 

I   "^  o  2-S~  o 

•^      —    ■>    r-    kr  C  •■:- 


-  "-    S    "    C    i3 


>■>  o 


"  ... 


M         'qq  -ri 


Oh    r  "2 

I  si 

I      £  3 


O    CO         O 

PhWSp3 


c3.£2  «-C   «" 


DIFFEEEXTIAL    DIAGNOSIS  525 

majority  of  these  cases  occur  during  the  last  half  of  the  first  year  of  life, 
but  this  disease  may  occur  as  late  as  the  third  or  fourth  year.  The  imma- 
turity of  the  blood  of  the  infant  makes  it  especially  vulnerable  to  toxic 
and  other  injurious  influences,  so  that  the  normal  blood  picture  at  this 
age  is  easily  disturbed  by  causes  which  later  in  life  would  have  little  effect 
upon  the  mature  blood. 

Chronic  gastrointestinal  intoxication  associated  with  artificial  feeding 
is  the  most  important  exciting  factor.  Unhygienic  surroundings,  diarrhea, 
constipation,  chronic  indigestion,  syphilis,  rickets,  and  secondary  anemias 
are  the  usual  antecedents  of  this  condition.    It  is  rare  in  breast-fed  babies. 

Symptomatology. — Blood  Picture. — The  hemoglobin  and  red  blood 
corpuscles  are  markedly  diminished,  the  former  to  20  or  30  per  cent.,  the 
latter  to  2,000,000  or  3,000,000  to  the  c.  mm. ;  in  rare  cases  to  under  1,000,- 
000.  The  red  corpuscles  vary  greatly  in  shape  (poikilocytosis) ;  small  red 
cells  (microcytes)  and  large  red  cells  (megalocytes)  are  present,  nucleated 
forms  (normoblasts  and  megaloblasts)  may  be  found,  and  polychromato- 
philia  may  occur.  The  white  blood  cells  are  increased,  a  leukocytosis  of 
from  30,000  to  50,000  being  common.  Mononuclears  and  polymorphonu- 
clears predominate,  eosinophiles  are  commonly  present,  and  neutrophilic 
and  eosinophilic  myelocytes  may  be  found. 

Other  Symptoms. — Pallor  of  the  skin  and  mucous  membranes  is  very 
marked.  The  spleen  is  enlarged,  hard,  not  tender  to  the  touch.  It  may 
extend  as  low  as  the  crest  of  the  ilium,  or  may  be  felt  but  slightly  below 
the  edge  of  the  ribs.  Its  size  is  not  always  in  proportion  to  the  severity 
of  the  other  symptoms  of  this  disease,  yet  it  is  the  most  distinguishing 
feature  of  the  clinical  picture.  The  liver  is  commonly  slightly  enlarged, 
and  the  superficial  lymph  nodes  easily  palpable.  Slight  hemorrhages  into 
the  skin  and  mucous  membranes  are  common.  An  irregular  fever  may 
occur. 

Obscure  digestive  disturbances  should  be  carefully  searched  for.  Con- 
stipated stools,  mucous  discharges,  intestinal  fermentation  and  indigestion 
are  common,  and  indican  is  usually  found  in  excess  in  the  urine.  The 
appetite  is  lost,  the  patient  is  listless  and  grows  progressively  weaker  and 
more  emaciated. 

Differential  Diagnosis. — From  leukemia,  the  disease  with  which  this 
condition  is  most  commonly  confused,  it  can  only  be  differentiated  by  re- 
peated blood  examinations.  The  blood  count  in  this  condition  shows  few 
myelocytes  and  a  moderate  leukocytosis,  while  in  leukemia  the  myelocytes 
are  present  in  large  numbers  and  the  leukocytes  enormously  increased. 
In  von  Jaksch's  disease  the  number  of  leukocytes  seldom  exceeds  50,000, 
and  there  is  practically  a  sustained  percentage  of  the  various  varieties  of 
leukocytes  in  spite  of  the  presence  of  the  myelocytes.  A  large  number  of 
nucleated  red  corpuscles  are  commonly  seen.  In  leukemia  the  liver  and 
lymph  nodes  are  much  more  enlarged. 

From  secondary  anemias  due  to  rickets,  syphilis  and  other  causes  the 
diagnosis  is  made  largely  by  the  severity  of  the  whole  clinical  syndrome. 


526  CHLOKOSIS 

The  spleen  is  much  larger,  the  leukocytosis  more  marked,  and  megalo- 
blasts  and  myelocytes  are  more  commonly  seen. 

Pernicious  anemia  rarely,  if  ever,  occurs  in  infancy,  and  is  not  to  be 
considered,  therefore,  in  the  differential  diagnosis,  although  the  blood 
picture  of  this  condition  may  very  closely  resemble  that  of  pernicious 
anemia  in  the  adult. 

Prognosis. — The  majority  of  these  cases  recover  under  careful  treat- 
ment. The  condition,  however,  is  always  to  be  considered  a  grave  one,  and 
the  prognosis  should  be  carefully  guarded  until  definite  signs  of  im- 
provement begin. 

Treatment. — The  indications  for  treatment  are  as  follows: 

First. — Eemove  the  intestinal  intoxication,  which  is  commonly  present. 
This  comprehends  the  careful  treatment  of  any  abnormal  gastrointestinal 
condition.  If  constipation  be  present,  mild  laxatives,  such  as  milk  of 
magnesia,  may  be  used  from  day  to  day,  with  a  dose  of  castor  oil  at  in- 
tervals of  four  or  five  days.  For  a  child  one  year  of  age,  one  grain  of 
either  salol,  betanaphthol,  or  carbonate  of  guaiacol  should  be  given  every 
three  hours  as  an  intestinal  antiseptic  throughout  the  treatment.  Great 
stress  should  be  laid  on  the  antiseptic  treatment  of  these  cases,  even  though 
gastrointestinal  disturbances  be  not  clearly  evident. 

Second. — Improve  the  infant's  nutrition  by  selecting  a  diet  within 
the  range  of  its  digestive  capacity,  and  at  the  same  time  of  such  a  character 
that  it  will  serve  nutritional  purposes.  Breast-milk  is  the  best  of  all  foods 
for  this  purpose,  and  many  of  these  cases  will  rapidly  improve  if  a  suitable 
wet-nurse  is  secured.  If  wet-nursing  be  impracticable,  these  infants  should 
be  fed  along  the  lines  outlined  in  the  chapter  on  Chronic  Intestinal  In- 
digestion.    Peptonized  milk  is  a  valuable  food  in  these  cases. 

Third. — Improve  the  blood  state  and  general  tone  of  the  infant  by 
keeping  it  out  of  doors  as  much  as  possible.  Fresh  air  is  very  important, 
and  if  the  weather  conditions  will  not  permit  the  fresh-air  treatment  at 
home,  a  change  of  climate  may  be  recommended. 

Fourth. — Treat  the  anemic  condition  directly  by  giving  some  form  of 
organic  iron,  preferably  combined  with  one  of  the  malt  preparations.  The 
use  of  iron,  however,  in  this  condition  must  not  be  persisted  in  if  the 
gastrointestinal  canal  is  disturbed  by  it.  In  such  cases  the  subcutaneous 
use  of  neutral  citrate  of  iron  in  %-grain  doses  is  of  value  (Friedlander). 
Arsenic  is  of  no  value  in  this  disease. 


CHAPTEE    LXIII 

CHLOROSIS 

Chlorosis  is  a  secondary  anemia  characterized  by  deficient  hemogenesis, 
producing  a  marked  decrease  in  hemoglobin  without  a  corresponding  re- 
duction in  red  blood  corpuscles.  This  results  in  a  low  color  index  and  a 
more  or  less  characteristic  greenish-yellow  color  of  the  skin. 


TREATMENT  527 

Etiology. — It  occurs  almost  exclusively  in  young  girls  about  the  age 
of  puberty,  and  for  this  reason  it  may  be  inferred  that  nervous  influences 
incident  to  the  development  of  the  sexual  organs  have  something  to  do  with 
its  production.  It  is  frequently  seen  in  brunettes.  It  is  extremely  rare  in 
boys.  The  most  important  predisposing  factors  are  believed  to  be  improper 
food,  a  deficiency  of  food,  fresh  air  and  sunlight.  It  occurs  most  commonly 
among  factory  and  shop  girls  who  spend  long  hours  under  unfavorable 
hygienic  conditions.  Constipation  and  intestinal  intoxication,  as  Andrew 
Clark  believed,  are  perhaps  important  factors.  True  chlorosis  probably 
does  not  occur  in  infancy  and  young  childhood,  although  the  blood  pic- 
ture presented  by  secondary  anemia  at  this  age  is,  as  already  noted,  of  the 
chlorotic  type. 

Symptomatology. — The  general  symptoms  are  very  like  those  of  well- 
marked  secondary  anemia.  The  skin  in  advanced  cases  of  chlorosis,  how- 
ever, has  a  yellowish-green  pallor  unlike  that  of  secondary  anemia,  and  the 
neurotic  disorders  which  are  so  marked  a  feature  of  the  secondary  anemias, 
are  not  so  pronounced  in  chlorosis,  although  the  patient  may  be  nervous, 
irritable  and  even  hysterical,  but  chlorosis  occurs  later  in  life,  and  for 
this  reason  the  nervous  system,  which  is  better  developed,  is  not  so  pro- 
foundly affected.  Cases  of  chlorosis  do  not  suffer  such  marked  nutritional 
disturbances  as  are  present  in  well-marked  secondary  anemias.  Shortness 
of  breath,  rapid  and  irregular  heart  action,  cardiac  dilatation,  hemic  mur- 
murs, epigastric  pain,  gastrointestinal  disturbances,  headache,  acne  and 
irregular  fever  may  occur.  Constipation  is  a  common  and  an  important 
symptom.     In  older  girls  dysmenorrhea  or  amenorrhea  may  be  present. 

The  BLOOD  PICTURE  is  very  characteristic,  and  by  it  the  diagnosis  is 
made.  The  hemoglobin  is  greatly  reduced;  it  may  be  as  low  as  20  or  30 
per  cent.,  while  the  red  blood  corpuscles  may  be  but  slightly  diminished  in 
number.  In  severe  cases,  however,  they  are  also  much  reduced,  but  not  in 
a  corresponding  degree  with  the  hemoglobin,  so  that  the  color  index  of 
the  blood  may  be  so  low  that  the  color  of  the  red  corpuscles  is  but  faintly 
discernible.  These  almost  colorless  corpuscles  vary  in  size  and  shape. 
Normoblasts  appear  in  small  numbers  in  severe  cases,  and  are  not  an  un- 
favorable sign,  since  they  indicate  blood  regeneration.  Microcytes  may 
be  present,  and  megaloblasts  are  extremely  rare.  The  leukocytes  are  nor- 
mal in  number,  but  there  may  be  a  relative  lymphocytosis. 

Diagnosis. — The  above  blood  picture  occurring  in  girls  between  the 
ages  of  twelve  and  eighteen  easily  suffices  to  make  a  diagnosis. 

Prognosis. — In  uncomplicated  cases  the  disease  yields  readily  to  treat- 
ment. 

Treatment. — Fresh  air,  sunshine,  and  good  food  greatly  facilitate  the 
cure.  A  carefully  selected  diet  of  nutritious  food,  within  the  range  of  the 
digestive  capacity  of  the  patient,  is  important.  The  gastrointestinal  canal 
must  be  kept  in  good  condition,  and  it  is  very  necessary  that  constipation 
be  overcome  with  non-irritating  laxatives.  The  proper  use  of  iron  is  by 
far  the  most  important  therapeutic  measure  in  the  treatment.  Under 
35 


528  PERNICIOUS   ANEMIA 

its  use  the  anemia  gradually  disappears,  and  the  blood  returns  to  its  nor- 
mal condition.  Iron  is  perhaps  best  given  in  the  form  of  Blaud's  pills, 
5  to  10  grains  after  meals,  until  the  blood  condition  is  materially  improved; 
the  dose  may  then  be  diminished  to  three  or  four  pills  a  day.  This  treat- 
ment is  to  be  continued  for  six  weeks,  or  longer,  if  necessary.  Saccharated 
carbonate  of  iron,  reduced  iron,  and  organic  iron,  in  combination  with 
malt  preparations,  may  be  used  if  gastrointestinal  conditions  demand  them. 
Two  or  three  grains  of  reduced  iron,  one  or  itwo  grains  of  quinin  and  one- 
thirtieth  of  a  grain  of  arsenic  may  be  advantageously  combined  in  the 
same  capsule.  Forchheimer  recommends  that  five  grains  of  betanaphthol 
or  salol  be  given  before  meals,  in  connection  with  the  iron  therapy. 

Patients  recovering  from  chlorosis  should  not  be  allowed  to  return  to 
the  same  unhygienic  surroundings  under  which  they  developed  the  disease ; 
otherwise  relapses  may  occur. 


CHAPTER    LXIV 

PERNICIOUS    ANEMIA 

This  is  a  very  grave  form  of  anemia.  It  is  characterized  by  a  well- 
defined  blood  picture  and  by  severe  constitutional  symptoms,  which,  al- 
though subject  to  strange  remissions  in  severity,  gradually  grow  worse 
until  in  the  great  majority  of  cases  death  results.  It  is  an  extremely  rare 
disease  in  childhood,  but  when  it  does  occur  it  presents  the  same  clinical 
picture  as  in  the  adult. 

Etiology. — The  fish  tapeworm,  the  hookworm  and  the  malarial  parasite 
may  produce  a  form  of  pernicious  anemia  in  which  the  blood  picture 
is  identical  with  the  ordinary  form  of  this  disease,  whose  etiology  is  not 
understood.  In  childhood  it  is  believed  to  be  associated  with  syphilis, 
rickets,  and  chronic  intestinal  disorders,  and  rarely  to  be  developed  from 
severe  forms  of  secondary  anemia. 

Symptomatology. — General  Symptoms. — The  symptoms  are  the  same 
as  in  the  adult.  There  is  marked  and  progressive  pallor  of  the  skin,  asso- 
ciated with  muscular  weakness,  dyspnea,  and  heart  symptoms  similar  to 
those  found  in  severe  secondary  anemias.  Vertigo,  tinnitus,  edema,  gas- 
trointestinal disorders,  associated  with  pain,  more  or  less  marked  disturb- 
ance of  the  functions  of  the  spinal  cord,  and  hemorrhages  into  the  skin 
and  from  the  mucous  membranes  very  frequently  occur.  The  diagnosis, 
however,  of  the  disease  is  made  from  the  blood  picture. 

Blood  Picture. — There  is  a  marked  reduction  in  the  number  of  red 
blood  corpuscles,  in  advanced  cases  as  low  as  1,000,000  per  c.  mm.,  and 
even  less.  The  hemoglobin  is  also  reduced,  but,  as  a  rule,  not  to  so  great 
an  extent  as  the  corpuscles,  so  that  each  red  cell  contains  an  excess 
of  hemoglobin.  This  produces  a  high  color  index,  and  is  one  of  the  most 
characteristic  of  the  blood  findings,  especially  in  children,  since  the  color 


TEEATMENT  529 

index  with  them  in  all  other  forms  of  anemia  is  comparatively  low.  Ex- 
treme poikilocytosis  and  basophilia  are  commonly  present,  and  the  size  of 
the  red  blood  corpuscles  is  in  the  average  increased;  megalocytes  are  com- 
mon; this  is  an  important  diagnostic  sign.  Polychromatophilia  frequently 
occurs.  Normoblasts  and  megaloblasts  are  seen,  the  former  in  larger 
numbers.  The  red  cells  lose  their  rouleaux  formation.  The  leukocytes 
are  normal  or  subnormal  in  number,  but  the  polynuclear  cells  are  relatively 
diminished  and  myelocytes  may  be  present. 

Eemissions. — This  is  a  disease  in  which  strange  remissions  may  ap- 
pear in  the  general  symptoms  and  in  the  blood  picture.  During  one  of 
these  remissions  the  patient  improves  over  a  period  of  some  months,  and 
upon  this  change  false  hopes  are  not  infrequently  founded.  Suddenly, 
without  apparent  cause,  there  is  an  exacerbation  in  all  of  the  symptoms, 
and  the  disease  progresses  steadily  downward. 

Diagnosis. — When  a  case  presents  the  symptoms  and  blood  picture  of 
pernicious  anemia,  the  stools  must  be  carefully  examined  for  evidences  of 
the  fish  tapeworm  and  the  hookworm,  and  the  blood  examined  for  the 
malarial  parasite.  These  etiological  factors  excluded,  the  diagnosis  of  the 
ordinary  form  of  pernicious  anemia  is  made.  In  children,  however,  as 
previously  noted,  the  blood  picture  in  severe  secondary  anemias  may 
closely  resemble  that  of  pernicious  anemia,  but  the  rarity  of  pernicious 
anemia  in  childhood  and  the  comparatively  low  color  index  in  secondary 
anemias,  when  taken  in  connection  with  the  blood  pictures  of  the  two 
conditions,  should  make  the  diagnosis  clear.  If  doubt  remains  for  a  time, 
the  different  course  of  the  two  conditions  will  clear  the  diagnosis.  Eosino- 
philia  in  connection  with  the  typical  blood  picture  of  pernicious  anemia 
suggests  intestinal  parasites  as  the  cause. 

Treatment. — The  treatment  is  the  same  as  in  the  adult,  and  is  unsatis- 
factory. It  is  questionable  whether  drugs  of  any  kind  influence  the  course 
of  this  disease.  Arsenic,  however,  has  been  for  a  long  time  and  is  still 
in  favor.  It  is  to  be  given  in  gradually  increasing  doses  until  the  physio- 
logical effects  of  the  drug  are  produced,  and  then  diminished  to  a  moder- 
ate-sized tonic  dose  suitable  to  the  age  of  the  child.  Careful  attention  to 
the  gastrointestinal  canal,  looking  to  the  avoidance  of  intestinal  intoxica- 
tion, is,  perhaps,  the  most  important  therapeutic  measure.  Salol  and 
betanaphthol  should  be  given  over  a  long  period  of  time.  A  wholesome 
outdoor  life  is  important. 

In  those  cases  due  to  the  fish  tapeworm,  the  hookworm  or  the  malarial 
parasite,  treatment  should,  of  course,  be  directed  toward  the  removal  of 
these  causative  factors. 


530  LEUKEMIA 

CHAPTEK    LXV 
LEUKEMIA 

Leukemia  is  a  blood  disease  manifesting  itself  by  a  great  increase  in 
the  leukocytes  and  by  pathological  changes  in  the  bone  marrow,  spleen, 
liver  and  lymph  nodes.  It  is  very  uncommon  in  infancy  and  childhood, 
but  does  occur. 

Etiology. — The  etiology  of  this  condition  is  not  at  all  clear,  but  in 
childhood  it  is  believed  to  be  etiologically  related  to  syphilis,  rickets, 
chronic  gastrointestinal  conditions,  malaria,  and  severe  secondary  anemias. 

Symptomatology. — The  symptoms  of  this  disease  in  childhood,  as  in 
adult  life,  appear  in  two  rather  well-marked  clinical  types,  which  are 
largely  distinguished  by  the  blood  picture  presented.  The  myeloid  type 
is  much  the  most  common  in  the  adult,  and  the  lymphoid  type  comprises 
the  majority  of  the  cases  in  infancy  and  early  childhood.  In  children 
these  two  types  are  very  commonly  mixed,  the  blood  picture  being  a  com- 
bination of  the  two.    In  the  adult  the  types  are  more  clearly  defined. 

Blood  Picture. — In  both  types,  hemoglobin  and  red  blood  corpuscles 
are  diminished  and  nucleated  forms  are  seen,  but  these  changes  are  un- 
important from  the  standpoint  of  diagnosis.  It  is  the  leukocyte  blood 
picture  which  not  only  differentiates  the  two  types,  but  distinguishes  this 
disease  from  all  others. 

In  the  myeloid  form  we  have  an  enormous  increase  in  leukocytes; 
100,000  to  500,000  are  commonly  found.  A  large  number  of  myelocytes 
of  different  sizes  are  present;  this  is  the  most  characteristic  feature  of 
the  blood  picture.  The  large  mononuclears  and  the  poh'nuclear  and 
mononuclear  eosinophiles  are  increased.  The  polynuclear  neutrophiles  and 
mast  cells  are  also  increased,  but  not  to  the  same  extent  as  the  other 
cells  mentioned.  The  special  feature  of  this  blood  picture  is  an  enor- 
mous leukocytosis  with  a  great  increase  in  myelocytes,  polynuclear  eosino- 
philes and  mast  cells. 

In  the  lymphoid  form  the  lymphocytes  are  greatly  increased  in  num- 
ber, even  as  high  as  95  per  cent,  of  the  leukocytes  present ;  myelocytes  and 
mast  cells  may  be  present.  There  is  a  diminution  in  the  amount  of 
hemoglobin  and  red  blood  corpuscles,  and  some  nucleated  forms  may  be 
seen. 

General  Symptoms. — The  onset  and  course  of  the  disease  are  much 
more  rapid  in  young  children  than  in  the  adult.  It  commonly  progresses 
to  a  fatal  termination  within  a  few  months.  The  whole  course  of  the 
disease  may  be  embraced  within  a  single  month.  The  pallor  of  the  skin 
and  mucous  membranes  is  very  pronounced;  gastrointestinal  disturbances 
are  common ;  vomiting  is  a  frequent  symptom ;  hemorrhages  may  occur 
from  the  nose  and  other  mucous  membranes;  blood  may  be  present  in  the 


PURPURA  531 

stools,  and  subcutaneous  hemorrhages  producing  dark  blue  spots  may  oc- 
cur from  slight  blows  upon  the  skin.  The  appetite  is  lost,  the  child  is 
nervous,  irritable,  and  rapidly  and  progressively  fails  in  strength.  The 
spleen  is  always  enlarged  and  may  be  enormously  so,  extending  even  to 
the  crest  of  the  ilium.  The  liver  dullness  is  frequently  greatly  increased 
and  the  lymph  nodes  and  other  lymphoid  structures,  including  the  tonsils 
and  adenoids,  are  also  notably  increased  in  size.  As  the  disease  progresses 
the  child's  strength  rapidly  fails,  there  is  shortness  of  breath,  the  heart  is 
weak,  and  rapid  and  repeated  hemorrhages  may  greatly  aggravate  the 
prostration.  The  temperature  may  be  normal,  or  may  range  from  time 
to  time  as  high  as  102°  or  103  "F.     Death  occurs  from  exhaustion. 

Prognosis.  — It  is  questionable  whether  any  of  these  cases  occurring 
in  infancy  and  young  childhood  ever  recover. 

Treatment. — The  treatment  is  unsatisfactory,  purely  symptomatic,  and 
directed  toward  the  relief  of  suffering;  any  therapeutic  measures  to  this 
end  are  justifiable.  The  X-ray  treatment  of  these  cases,  after  a  thor- 
ough trial,  has  been  found  to  be  without  therapeutic  value. 


CHAPTER    LXVI 

PUEPUEA 

Purpura  is  the  name  applied  to  a  condition  in  which  there  is  a  transi- 
tory and  nonhereditary  hemorrhagic  diathesis,  caused  by  toxins  and  other 
contributing  etiological  factors.  It  is  characterized  by  a  skin  eruption 
produced  by  small  spontaneous  hemorrhages  occurring  in  the  subcutaneous 
tissues.  The  hemorrhagic  spots  thus  produced  are  bluish,  but  gradually 
fade  to  a  brown  and  then  yellow  color.  This  yellow  pigment  is  slowly 
absorbed,  removing  all  discoloration,  so  that  the  skin  may  present  a  normal 
color  within  a  week  or  ten  days  after  the  initial  lesion.  jSTew  crops  of 
purpuric  spots  occurring  from  time  to  time  may  prolong  the  eruption 
for  an  indefinite  period.  These  purpuric  spots  do  not  disappear  upon 
pressure.  The  eruption  may  appear  as  fine  petechial  hemorrhagic  points, 
but,  as  a  rule,  the  spots  are  larger,  approaching  in  size  a  split  pea,  and 
sometimes  large,  irregular  hemorrhagic  patches  occur,  resembling  an  ordi- 
nary bruise  of  the  skin.  It  may  occur  on  any  part  of  the  body,  but  it  is 
most  common,  and  usually  first  appears,  on  the  legs,  especially  over  the 
shin  bones.  The  frequent  association  of  purpura  with  urticaria,  erythema 
exudativum,  and  localized  edema,  in  the  various  symptom  groups  classi- 
fied as  "purpuras,"  indicates  that  the  same  toxins  may  produce  these 
various  skin  lesions  by  their  action  through  the  nervous  mechanism  that 
controls  blood  and  lymph  vessels.  This  association  of  symptoms  in  part 
helps  to  establish  the  more  or  less  clearly  defined  symptom  groups  below 
referred  to.  The  purpuric  eruption  very  commonly  occurs  as  a  symptom 
of  constitutional  disorders,  toxic,  cachectic  and  nervous  in  their  character. 


532  PURPURA 

These  symptomatic  purpuras  are  not  separate  clinical  syndromes,  the  rash 
being  but  one  of  a  large  group  of  symptoms  which  belong  to  some  well- 
defined  constitutional  disorder.  In  other  instances  the  purpura  occurs 
as  the  all-important  clinical  feature  of  a  distinct  syndrome,  whose  etiology 
is  more  or  less  obscure.  These  cases  are  spoken  of  as  idiopathic,  to  dis- 
tinguish them  from  the  clearly  defined  secondary  purpuras.  It  may  be 
that  the  various  forms  of  purpura  are  merely  clinical  syndromes  repre- 
senting different  phases  and  different  degrees  of  the  same  hemorrhagic 
diathesis,  but  they  are  here  described  as  distinct  disease  pictures  in  order 
that  the  clinical  course  of  the  various  symptom  groups  of  this  condition 
may  be  more  clearly  understood. 

The  symptom-complex  of  the  following  idiopathic  purpuras  will  be 
here  briefly  described :  Purpura  simplex,  purpura  f ulminans,  purpura 
hemorrhagica,  Henoch's  purpura,  and  purpura  rheumatica. 

Etiology. — It  is  believed  that  nearly  all  of  the  worst  forms  of  purpura 
are  due  to  toxic  substances  circulating  in  the  blood,  and  that  they  act  not 
only  upon  the  nervous  system,  producing  profound  vasomotor  disturb- 
ances, but  also  directly  on  the  endothelial  lining  of  the  smaller  blood  ves- 
sels, producing  degenerative  changes.  It  is  known  that  blood  coagulation 
is  impaired,  that  the  blood  platelets  are  diminished  and  that  the  blood  clot 
formed  from  purpuric  blood  does  not  contract  firmly.  It  is  believed,  es- 
pecially by  French  writers,  that  functional  disturbances  of  the  liver  are 
etiologically  related  to  this  condition. 

Symptomatic  Purpura. — Symptomatic  purpura  occurs  not  uncommonly 
in  association  with  nervous  disorders,  but  this  form  is  rare  in  children.  It 
may  also  rarely  result  from  the  administration  of  drugs,  such  as  iodid  of 
potash,  mercury,  belladonna,  antipyrin,  quinin,  salicylic  acid,  chloral, 
ergot,  and  potassium  chlorate.  A  very  pronounced  form  of  purpura  can 
be  quickly  produced  by  snake  venom.  The  most  common  cause  of  sec- 
ondary purpura  in  infancy  and  childhood  are  the  acute  infections.  It  may 
occur  as  part  of  the  symptom-complex  in  smallpox,  diphtheria,  scarlet 
fever,  measles,  cerebrospinal  meningitis,  septicemia  and  septic  endocarditis, 
and  when  it  does  occur  in  these  conditions  it  adds  great  gravity  to  the 
prognosis.  In  infancy,  secondary  purpura  may  occur  in  hereditary  syph- 
ilis, rickets,  tuberculosis,  chronic  ileocolitis,  the  severe  secondary  anemias, 
leukemia,  and  in  all  conditions  producing  a  profound  malnutrition. 

Purpura  Simplex. — This  condition  is  characterized  by  a  purpuric  erup- 
tion usually  symmetrical  in  its  distribution.  It  first  appears  on  the  legs 
and  may  be  confined  to  the  lower  extremities,  but  it  usually  appears  in 
other  parts  of  the  body.  The  rash,  commonly  petechial  in  character,  ap- 
pears suddenly  without  constitutional  symptoms.  There  is  little  or  no 
fever.  Nausea,  vomiting  and  digestive  disturbances  may  or  may  not  be 
present.  The  disease  runs  its  course,  as  a  rule,  to  a  favorable  termina- 
tion within  from  two  to  four  weeks.  The  prolongation  of  this  condition 
is  due  to  the  fact  that  the  eruption  comes  out  in  successive  crops. 

Purpura  Fulminans. — This  is  a  rare  and  very  severe  form,  commonly 


PURPURA    HEMORRHAGICA  533 

terminating  fatally  within  one  or  two  days;  death  may  occur  within  the 
first  twelve  hours,  or  may  be  postponed  for  four  or  five  days.  In  a  case 
which  I  reported  some  years  ago  death  occurred  within  twenty-four  hours. 
This  case  was  a  helpless,  idiotic,  epileptic  child,  nine  years  of  age,  living 
under  very  unfavorable  hygienic  surroundings,  and  in  the  same  room  with 
two  cases  of  malignant  diphtheria,  one  of  which  died  on  the  same  day  as 
this  patient.  There  was  no  fever  and  no  hemorrhage  from  mucous  mem- 
branes; the  onset  of  the  disease  was  marked  by  irritability,  refusal  to  take 
food,  and  the  appearance  of  a  great  number  of  dark  blue  hemorrhagic 
spots  over  the  legs,  scrotum,  and  abdomen,  these  spots  rapidly  increasing 
in  size  until  they  ran  together,  producing  a  dark  blue  discoloration  over 
the  parts  above  named.  Small  hemorrhagic  spots  appeared  also  over  other 
portions  of  the  body,  profound  prostration  was  quickly  followed  by  delirium, 
stupor,  coma,  and  death.  This  is  a  typical  clinical  picture  of  this  symp- 
tom group.  Convulsions,  vomiting  and  high  fever  may  be  present  in  these 
cases,  and  albumin  is  usually  found  in  the  urine.  In  the  case  above  de- 
tailed the  inference  is  that  the  disease  was  produced  by  the  toxins  of 
diphtheria,  although  no  evidence  of  diphtheria  appeared  in  the  throat. 
Many  of  these  cases  are  believed  to  be  foudroyant  cases  of  smallpox, 
measles,  scarlet  fever  and  other  infections.  The  patients,  however,  as  a 
rule,  do  not  live  long  enough  to  develop  the  characteristic  symptoms  of 
these  diseases. 

Purpura  Hemorrhagica. — Purpura  hcnorrhagica  is  characterized  by 
hemorrhages  from  mucous  membranes,  and  is  thereby  distinguished  from 
other  forms  of  purpura.  These  hemorrhages,  which  are  the  characteristic 
feature  of  the  disease,  occur  apparently  without  exciting  cause.  Their  most 
common  site  is  the  nose ;  bleeding  may  also  occur  from  the  mouth,  especially 
the  gums,  from  the  kidneys,  the  intestinal  canal,  and,  in  fact,  from  any 
mucous  membrane.  In  a  case  which  I  reported,  the  bleeding  from  the 
nose  persisted  almost  continuously  for  six  days,  and  bled  at  intervals 
during  the  next  three  or  four  days,  until  on  the  tenth  day  of  the  disease 
a  blood  examination  showed  21  per  cent,  of  hemoglobin  and  1,300,000  red 
blood  corpuscles.  The  resulting  anemia  which  occurs  in  some  of  these 
cases  is  very  great,  and  in  those  cases  that  recover,  the  increase  in  the  num- 
ber of  corpuscles  is  so  much  more  rapid  than  the  increase  in  hemoglobin, 
that  the  anemia  assumes  for  a  time  a  chlorotic  type.  This  is  illustrated 
in  the  chart  taken  from  the  report  of  the  case  above  referred  to. 

The  purpuric  rash  in  this  condition  is  widely  distributed  over  the  body, 
beginning,  as  a  rule,  on  the  legs;  the  hemorrhagic  spots  vary  in  size  froni 
a  pinhead  to  a  silver  dollar.  In  the  case  above  referred  to,  the  baby  sister 
of  the  patient  struck  him  a  slight  blow  on  the  forehead  with  an  Easter 
egg,  producing  a  dark  blue,  irregular  hemorrhagic  spot.  The  spots,  how- 
ever, as  a  rule,  appear  spontaneously  and  may  occur  in  crops  from  time 
to  time  throughout  the  course  of  the  disease.  Fever,  nausea,  vomiting 
and  gastrointestinal  disturbance  may  or  may  not  be  present.  The  tempera- 
ture, in  the  early  stages,  ranges  in  the  neighborhood  of  103 °F.    Albumin 


534 


PUEPUEA 


may  be  found  in  the  urine,  and  acute  nephritis  is  the  most  common  serious 
complication.  Arthritis  may  occur,  but  is  not,  as  a  rule,  a  feature  of  this 
disease.  Edema  may  also  be  present,  but  erythema  and  urticaria,  so  com- 
monly present  in  other  forms  of  purpura,  are  rarely  seen  in  this  condition. 
The  disease  is  a  serious  one,  lasting  from  two  to  eight  weeks,  but  most 
of  the  cases  recover.  In  rare  instances  the  disease  may  resemble  typhoid 
fever,  having  a  continuous  fever,  intestinal  hemorrhages,  great  prostration, 
delirium,  and,  in  fatal  cases,  coma.  These  cases,  however,  should  be  easily 
differentiated  from  typhoid  by  the  absence  of  the  Widal  reaction,  and  by 
a  careful  study  of  the  two  symptom  groups. 


4,ooo,(yx>  corpuscles  and  80  per  cent,  hemoglobin 


3,500,000 

" 

"  70 

3,000,000 

>t 

•■  60 

2,500,000 

" 

••  50 

2,000,000 

•• 

•■  40 

1,500,000 

•• 

*•  30 

I/XX>,O0O 

«■ 

••   20 

April 

May 

*/une 



■rrr- 



-■-' 

( 

^' 

.'- 

-•'' 

/ 

,•' 

/ 

/ 

.■■ 

/ 

rp 

Soli3  line  =  number  of  corpuscles.     Broken  line  =  percentage  hemoglobin. 
Fig.  82.  Diagram  Showing  Blood  Changes  in  a  Case  of  Purpura  Hemorrhagica. 

Henoch's  Purpura. — This  form,  first  described  by  Henoch,  occurs  most 
commonly  in  children.  The  purpura  is  associated  with  attacks  of  severe 
abdominal  pain  and  polyarthritis.  The  onset  may  be  marked  by  headache, 
fever,  prostration,  and  the  outbreak  of  a  purpuric  rash.  In  some  cases, 
however,  the  arthritis  or  intestinal  colic  may  precede  the  eruption,  which 
is  frequently  accompanied  by  urticaria,  erythema,  and  angioneurotic 
edema.  Osier  has  called  attention  to  the  fact  that  in  this  form  of  pur- 
pura, as  in  others  associated  with  erythema,  there  may  be  great  variations 
in  the  appearance  of  the  skin;  the  purpura,  erythema,  urticaria  and 
localized  edema  may  all  be  present  in  an  individual  case,  or  again  various 
combinations  of  these  skin  lesions  may  occur,  and  any  one  may  be  absent. 
Recurring  attacks  of  severe  abdominal  pain  is  the  characteristic  symptom. 
It  may  be  associated  with  violent  and  prolonged  vomiting,  and  early 
constipation  is  followed  by  diarrhea;  the  stools  may  contain  blood.  The 
pain  is  usually  referred  to  the  umbilicus,  and  is  associated  with  abdominal 
resistance  and  with  tenderness  over  the  upper  portion  of  the  abdomen. 
Arthritis  occurs  in  practically  all  of  the  severe  cases.  There  may  be  pain 
and  swelling  in  one  or  more  joints,  and  successive  joints  may  be  involved. 

The  acute  symptoms  of  an  attack  last  from  a  few  days  to  a  week; 
within  this  time  the  eruption  fades,  the  pain  and  tenderness  of  the  joints 
disappear,  the  gastrointestinal  disturbances  cease,  and  the  patient  is  ap- 
parently convalescent.  Within  a  wopk,  however,  the  whole  symptom  group 
above  detailed  may  recur,  and  repeated  attacks  of  this  character  with  inter- 
vening periods  of  apparent  convalescence  may  prolong  the  illness  for 
months,  but  true  convalescence  is  established  in   the  majority  of  cases 


TEEATMENT  535 

within  a  month  or  six  weeks.  In  a  few  instances  the  disease  becomes 
chronic  and  lasts  over  a  period  of  years.  Acute  nephritis  is  a  dangerous, 
and  hy  far  the  most  common,  complication;  cerebral  hemorrhage,  endo- 
carditis and  pericarditis  may  occur. 

The  prognosis,  on  the  whole,  is  good,  especially  in  children.  About 
ten  per  cent,  of  these  cases  die  from  various  complications. 

Purpura  Rheumatica  {Schonleins  Disease). — This  is  seen  in  older  chil- 
dren, but  more  commonly  in  young  adults,  and  is  not  in  any  way  etiolog- 
ically  related  to  rheumatism,  although  it  may  begin  with  pharyngitis  and 
tonsillitis.  The  purpuric  rash  resembles  that  seen  in  simple  purpura.  It 
consists  largely  of  petechias  associated  with  slightly  larger  ecchymotic 
spots,  distributed  chiefly  over  the  lower  extremities,  but  other  parts  of 
the  body  may  be  involved.  In  some  cases  the  eruption  is  more  marked 
over  the  swollen  joints  and  spreads  from  joint  to  joint  with  the  arthritis. 

The  chief  characteristic  is  the  multiple  arthritis,  and  all  cases  of  ar- 
thritis associated  with  simple  purpura,  uncomplicated  by  abdominal  colic 
and  by  hemorrhage  from  mucous  membranes,  are  classed  under  this  syn- 
drome. The  arthritis  usually  affects  the  knees  and  ankles  in  these  cases 
and  commonly  disappears  within  a  week. 

When  the  arthritis  is  the  initial  lesion  and  is  associated  with  fever, 
as  it  is  in  many  of  the  cases,  a  diagnosis  of  rheumatism  is  ordinarily 
made.  The  character  of  the  trouble,  however,  is  soon  made  clear  by  the 
appearance  within  a  few  days  of  the  purpuric  eruption  and  possibly  the 
subsequent  association  of  erythema,  urticaria  and  localized  edema  with 
the  purpuric  rash.  The  erythema,  urticaria,  edema  of  the  hands  and  feet 
and  even  typical  angioneurotic  edema,  which  is  associated  with  the  pur- 
pura in  many  of  the  cases  of  purpura  rheumatica,  present  a  clinical  pic- 
ture which  may  closely  resemble  Henoch's  purpura,  with  the  exception  of 
the  gastrointestinal  symptoms  of  that  disease.  Albuminuria  may  occur,  but 
nephritis  and  other  complications  seen  in  Henoch's  purpura  are  very  rare. 

These  cases  run  a  benign  course  and  are  commonly  convalescent  with- 
in a  month;  relapses,  however,  are  not  uncommon. 

Treatment. — The  treatment  of  symptomatic  purpura  calls,  in  the  first 
place,  for  the  treatment  of  the  underlying  causative  condition,  and,  in 
the  second  place,  for  the  routine  treatment  of  purpura  as  here  outlined,  if 
the  treatment  recommended  is  not  contraindicated  by  the  primary  disease. 

General  Treatment. — General  treatment  applicable  to  all  forms  of 
purpura.  Absolute  rest  in  bed  until  all  symptoms  are  under  control  is 
of  great  importance.  The  patient  should  be  kept  quiet,  and  should  be 
in  the  hands  of  competent  nurses  who  can  protect  him  from  all  possible 
injuries  to  the  skin  and  mucous  membranes.  Fresh  air,  day  and  night,  is 
essential.  When  the  weather  will  permit  and  the  surroundings  are  fa- 
vorable, the  bed  of  the  patient  should  be  placed  out  of  doors  for  as  much 
of  the  twenty-four  hours  as  is  practicable. 

Diet. — Milk  and  cereals  should  be  the  basis  of  the  diet,  and  orange 
juice  and  other  fruit  juices  should  be  given.     Since  purpura  is  a  toxic 


536  PURPURA 

condition,  and  since  the  kidneys  very  commonly  give  way  under  the  irri- 
tation of  excreting  these  toxins,  it  is  most  important  that  these  patients 
should  be  dieted  as  they  are  in  scarlet  fever  with  the  idea  not  only  of 
eliminating  toxins,  but  of  protecting  the  kidneys  and  other  excretory  or- 
gans. Rich,  albuminous  foods,  and  strong  beef  broths,  should,  therefore, 
be  avoided  in  the  treatment  of  all  forms  of  purpura  during  the  acute  stage 
of  the  disease.  In  addition  to  the  diet  above  recommended,  water  should 
be  given  freely  to  assist  in  the  elimination  of  toxins  and  in  the  flushing  out 
of  the  excretory  organs.  During  convalescence  the  diet  may  be  increased 
and  fruits,  vegetables  and  albuminous  foods  may  be  given. 

Cathartics  serve  a  useful  purpose  and  are  indicated  in  all  forms 
of  purpura  not  complicated  by  intestinal  hemorrhage.  Calomel,  Rochelle 
salts,  sulphate  of  soda,  sulphate  of  magnesia  and  phosphate  of  soda  not 
only  remove  offensive  matter  from  the  intestinal  canal  and  eliminate  tox- 
ins through  the  intestinal  wall,  but  they  also  unload  the  portal  circula- 
tion and  perhaps  favorably  influence  the  functional  inactivity  of  the  liver 
which  is  believed  to  be  present  in  most  cases  of  purpura. 

Hydrotherapy. — Elimination  of  toxins  should  also  be  promoted 
through  the  skin.  This  may  be  accomplished  by  the  giving  of  one  or  two 
warm  alkaline  baths  each  day;  common  salt,  sea  salt  or  bicarbonate  of 
soda  may  be  used  in  these  baths,  and  great  care  must  be  taken  in  handling 
the  patient,  that  fresh  ecchymoses  may  not  be  produced  by  bruising  the  skin. 

Medical  Treatment. — Calcium  lactate  is  believed  to  exert  a  favor- 
able influence  by  increasing  the  coagulability  of  the  blood;  it  may  be 
given  in  five-grain  doses  to  a  child  six  years  of  age,  increasing  the  dose 
one  grain  for  each  year  of  life  until  the  maximum  dose  of  15  grains  three 
times  a  day  is  reached.  Fowler's  solution  has  been  extensively  used  and 
is  believed  to  be  of  value  in  these  cases;  it  should  be  given,  as  in  chorea, 
in  gradually  increasing  doses  until  improvement  begins,  or  until  the  pa- 
tient is  taking  10  drops  three  times  a  day.  It  is  perhaps  of  special  value 
in  those  cases  that  are  believed  to  be  of  cachectic  or  neurotic  origin,  and 
are  associated  with  marked  nervous  symptoms.  It  is  contraindicated 
in  Henoch's  purpura  and  in  all  forms  where  there  is  gastrointestinal  irri- 
tation. 

Iron  is  a  remedy  of  little  or  no  value  during  the  acute  stages  of  this 
disease,  but  is  a  remedy  of  very  great  value  during  convalescence.  Its 
special  value  is  in  those  cases  where  a  more  or  less  marked  anemia  re- 
sults. The  preparation  of  iron  selected  will  depend  largely  upon  the  age 
of  the  patient  and  the  condition  of  the  gastrointestinal  canal.  In  younger 
children  the  organic  iron  preparations  and  the  saccharated  carbonate  given 
with  some  form  of  malt  are  most  valuable.  In  older  patients  Blaud's  pills 
may  be  given. 

Treatment  of  the  Special  Forms. — The  prime  object  in  the  treat- 
ment of  purpura  hemorrhagica  is  to  control  as  soon  as  possible  the  bleed- 
ing from  the  mucous  membrane.  Where  the  bleeding  surface  can  be 
reached,  as  in  the  mouth  or  nose,  the.  parts  should  be  irrigated  with  a  1  to 


ETIOLOGY  537 

1,000  adrenalin  solution,  or  should  be  packed  with  cotton  saturated  with 
this  solution.  In  hemorrhages  from  the  stomach  adrenalin  may  be  taken 
internally  in  the  hope  that  it  may  act  locally  upon  the  bleeding  vessels. 
In  the  control  of  hemorrhage  the  bleeding  part  should  be  elevated  and 
absolute  rest  insisted  on;  the  patient  should  not  be  allowed  to  do  any- 
thing for  himself  that  can  be  done  by  others.  If  there  be  hemorrhage  from 
the  stomach  or  intestine,  the  prolonged  application  of  ice  to  the  abdomen 
should  be  resorted  to,  and  where  these  measures  fail,  5  or  10  minims  of 
adrenalin  solution  may  be  injected  hypodermically.  The  hemorrhage  once 
being  controlled,  rest  in  bed  and  absolute  quiet  should  still  be  insisted 
upon  for  a  period  of  a  week  or  ten  days,  and  during  this  time  the  general 
treatment  of  purpura  as  above  outlined  should  be  carried  out.  During 
convalescence  the  profound  anemia  which  has  resulted  from  the  hemorrhage 
demands  the  use  of  iron  in  large  doses.  Later  the  iron  may  be  combined 
with  arsenic,  and  this  treatment  continued  until  all  traces  of  the  anemia 
have  disappeared. 

During  the  acute  stage  of  Henoch's  purpura  the  gastrointestinal  condi- 
tion precludes  giving  anything  except  the  lightest  food,  such  as  cereal 
waters,  to  which  milk  may  be  added.  Laxative  medication,  preferably  cas- 
tor oil  or  sulphate  of  magnesia,  is  indicated  to  relieve  the  abdominal  pain. 
Osier  believes  that  the  pain  in  this  condition  is  due  to  an  edematous  con- 
dition of  the  intestinal  wall.  This  may  be  the  explanation  for  the  relief 
from  intestinal  pain  which  the  saline  cathartics  afford  in  this  disease.  In 
some  instances  it  may  be  necessary  to  give  morphin  hypodermically.  Ice- 
bags  to  the  abdomen  may  also  be  of  benefit.  As  the  intestinal  symptoms 
come  under  control  the  bowels  are  still  to  be  kept  open  with  saline  cathartics, 
and  milk  and  cereal  gruels  are  to  be  continued  until  all  danger  from  neph- 
ritis is  passed.     The  general  treatment  is  the  same  as  that  above  outlined. 

The  other  forms  of  purpura  require  no  special  treatment  other  than 
that  above  given.  In  purpura  fulminans  all  treatment  is  unavailing.  In 
purinira  rhenmatica  the  disease  runs  a  benign  course  and  responds  to  the 
routine  treatment  of  purpura.     Salicylates  are  of  no  value  in  this  disease. 


CHAPTER   LXVII 

HEMOPHTTJA 

Hemophilia  is  a  rare  disease,  characterized  by  an  hereditary  and  long- 
continued,  if  not  permanent,  predisposition  to  severe  and  ofttimes  uncon- 
trollable hemorrhages,  which  may  be  precipitated  by  traumas  so  slight 
as  to  be  undiscoverable.  Patients  suffering  from  this  disease  are  popularly 
known  as  "bleeders." 

Etiology. — Comparatively  little  is  known  of  the  pathology  and  etiology 
of  this  condition.  It  is,  however,  distinctly  hereditary,  running  through 
families  for  many  generations.    In  some  of  the  families  studied  the  disease 


538  HEMOPHILIA 

has  persisted  for  two  liundred  years.  The  hereditary  tendency  is,  in  the 
vast  majority  of  instances,  transmitted  through  females,  themselves  non- 
bleeders,  to  the  male  members  of  a  family,  thus  skipping  a  generation. 
Direct  transmission  from  parent  to  child  is  very  unusual.  It  has  a  great 
predilection  for  males;  females  are  comparatively  rarely  affected,  the  pro- 
portion being  about  as  one  to  twelve.  It  is  not  unusual  in  hemophiliac 
families  to  find  more  than  half  of  the  males  descended  from  the  female 
members  of  the  family  suffering  from  this  disease,  while  none  of  the 
females  and  none  of  the  males  descended  from  male  members  of  the 
family  have  the  disease.  In  rare  instances,  however,  it  should  be  remem- 
bered that  the  disease  may  descend  through  the  male  line  and  that  the 
females  may  be  affected. 

Age. — In  the  new-born  hemorrhages  from  this  cause  are  rare,  but  do 
occur.  This  disease,  however,  nearly  always  begins  in  early  childhood.  In 
65  per  cent,  of  the  cases  the  first  hemorrhage  appears  during  the  first 
or  second  year  of  life,  and  children  of  hemophiliac  families  who  have 
shown  no  symptoms  before  the  tenth  year  of  life  are  comparatively  safe. 
In  rare  instances,  however,  it  may  appear  in  adult  life.  It  is  especially 
rare  in  warm  climates. 

Symptomatology. — The  characteristic  hemorrhage  is  not,  as  a  rule,  vio- 
lent, but  it  is  long-continued  and,  if  controlled,  sooner  or  later  commonly 
recurs.  The  surface  from  which  the  blood  oozes  usually  shows  no  sign  of 
trauma.  The  first  hemorrhage  is  rarely  fatal,  but  the  subsequent  ones 
usually  cause  death  during  childhood;  less  than  15  per  cent,  reach  ma- 
turity. These  uncontrollable  hemorrhages  may  last  for  weeks,  or  until 
the  child  dies  from  exhaustion.  Spontaneous  hemorrhages  may  be  pre- 
ceded by  restlessness,  nervousness,  vertigo,  circulatory  disturbances,  and 
other  prodromal  symptoms.  If  the  patient  lives  to  maturity,  the  tendency 
to  these  hemorrhages  gradually  grows  less,  so  that  he  may  even  outgrow 
his  hemorrhagic  predisposition.  Very  rarely,  dangerous  and  even  fatal 
hemorrhages  occur  after  middle  life. 

A  family  history  of  hemophilia,  which  is  present  in  nearly  every  case, 
is  hardly  less  important  in  making  the  diagnosis  than  the  characteristic 
hemorrhages  above  described,  since  with  this  family  history  the  diagnosis 
may  be  made  with  the  onset  of  the  first  hemorrhage,  and  without  it  one 
must  wait  until  repeated  severe  and  almost  uncontrollable  hemorrhages 
have  occurred  before  making  the  diagnosis. 

In  two  of  the  three  cases  ^  reported  by  me,  the  bleeding  point  was  in 
the  median  line  of  the  upper  surface  of  the  tongue.  Hemorrhages  most 
commonly  occur  from  mucous  membranes,  especially  of  the  nose  and  throat. 
Catarrhal  diseases  of  the  nose  and  throat,  and  diseases  of  the  gums,  may 
precipitate  serious  and  even  fatal  hemorrhages.  Bleeding  may  also  occur 
from  the  bowels,  the  stomach,  any  portion  of  the  skin,  and,  in  fact,  from 
any  part  or  into  any  organ  of  the  body.  Subcutaneous  hemorrhages  pro- 
ducing hematomas  are  common.     These  hematomas  may  be  very  large, 

^Medical  News,  1892. 


TREATMENT  539 

and  may  be  associated  with  fever  and  gastrointestinal  symptoms.  Hemor- 
rhages into  the  skin  may  produce  ecchymotic  spots,  which  may  lead  to  some 
confusion  in  the  diagnosis  of  this  disease  from  purpura.  The  ecchymoses, 
however,  in  hemophilia  are  large,  irregular  in  shape,  and  not,  as  a  rule, 
widely  distributed. 

Arthritis  occurs,  sooner  or  later,  in  almost  every  case.  The  knees 
and  elbows  are  most  commonly  involved,  but  the  smaller  joints  may  also 
be  affected.  The  swelling  occurs  rapidly  and  is  produced  by  hemorrhage 
into  the  Joint  from  the  synovial  membrane.  In  the  beginning  there  is  no 
tenderness,  redness,  or  inflammation,  although  pain  may  be  present  as  a 
result  of  the  tension.  The  inflammatory  stage  quickly  follows,  during 
which  the  joint  is  somewhat  tender  and  red,  showing  a  subacute  inflamma- 
tion. From  this  injury  the  joint  may  entirely  recover,  or  permanent  anky- 
losis may  result.  Fever  and  pain  may  accompany  the  joint  symptoms,  but 
they  are  not  so  pronounced,  nor  so  transient  in  character,  as  they  are  in  the 
arthritis  associated  with  purpura. 

Pronounced  anemia  and  great  exhaustion  follow  the  long-continued 
hemorrhages  that  occur  in  these  cases.  The  microscopic  blood  picture  is 
that  of  severe  secondary  anemia.  The  pulse  becomes  rapid  and  thready, 
the  patient  is  nervous,  faint,  and  complains  of  shortness  of  breath  and 
great  exhaustion.  If  the  hemorrhage  is  controlled  the  patient  slowly 
convalesces,  perhaps  to  suffer  from  another  attack,  to  which  he  succumbs 
from  exhaustion. 

Diagnosis.  -In  the  vast  majority  of  instances  the  family  history,  the  re- 
peated hemorrhages,  and  the  subacute  arthritis  make  the  diagnosis  plain. 
In  rare  instances,  however,  the  occurrence  of  a  purpuric  rash  with  these 
symptoms,  and  the  absence  of  a  family  history  of  hemophilia,  may  make 
the  differential  diagnosis  between  this  condition  and  purpura  hemorrhagica 
a  very  difficult  matter. 

Prophylaxis. — The  members  of  hemophiliac  families  should  be  advised 
against  marriage.  This  applies  especially  to  the  females,  since  it  is 
through  them  the  disease  is  most  likely  to  be  transmitted.  The  children 
of  these  families  should,  during  infancy  and  young  childhood,  be  most 
carefully  guarded  from  injury,  and  should,  if  possible,  live  in  a  warm 
climate,  since  mild,  semitropical  climates  sometimes  exercise  a  decidedly 
protective  influence  against  the  hemorrhages  of  this  disease;  it  is  possible 
that  the  beneficial  results  of  a  warm  climate  are  due  to  the  comparative 
freedom  which  such  a  climate  offers  from  catarrhal  diseases  of  the  nose 
and  throat.  As  a  prophylactic  measure  the  gums  and  mucous  membranes 
of  the  mouth  should  be  carefully  washed  every  day  with  a  simple  alkaline 
antiseptic,  and  all  surgical  measures  of  every  kind,  including  the  pulling 
of  teeth  and  circumcision,  should  be  carefully  avoided. 

Treatment.  ^In  the  treatment  of  an  attack  the  control  of  the  hemor- 
rhage demands  first  consideration.  Long-continued  compression  of  the 
bleeding  part  is  the  most  valuable  measure.  Adrenalin,  a  sterile  solution 
of  gelatin,  and  perchlorid  of  iron  may  be  used  with  compression.     The 


540  HODGKIN'S   DISEASE 

great  difficulty  in  most  instances  is  to  reach  the  bleeding  point  in  such  a 
way  that  these  measures  may  be  satisfactorily  employed.  In  one  of  the 
cases  reported  by  me^  the  tongue  was  compressed  by  a  clamp,  which  held 
a  small  piece  of  cotton,  saturated  with  Monsell's  solution,  against  the 
bleeding  point  on  its  anterior  surface.  The  grasp  of  the  instrument  was 
now  and  then  slightly  relaxed  to  allow  better  circulation  in  the  tip  of  the 
tongue.  After  two  hours  of  such  treatment  the  clamp  was  removed  and  a 
hemorrhage    which  had  lasted  for  five  consecutive  days    was  controlled. 

Calcium  lactate  in  5-  to  15-grain  doses,  depending  upon  the  age  of 
the  child,  should  be  given  three  times  a  day  for  a  period  of  four  or  five 
days,  or  until  the  hemorrhage  is  controlled.  A  number  of  observers  have 
reported  good  results  from  this  remedy,  and  have  recommended  that  it 
be  given  at  least  one  day  in  every  week  in  the  subsequent  treatment  of 
these  cases. 

Serum  Treatment. — Recent  reports  indicate  that  standardized  ani- 
mal blood  serum  is  a  valuable  remedy  in  stopping  the  hemorrhage  and  in 
controlling,  at  least  temporarily,  the  hemorrhagic  tendency.  It  is  to  be 
injected  in  doses  of  10  to  20  c.  c,  and  this  dose  repeated,  if  necessary, 
every  second  day  until  100  c.  c.  have  been  given.  The  local  application  of 
the  serum  to  bleeding  mucous  membranes  is  also  recommended  for  con- 
trolling hemorrhages.  If  a  simple  standardized  sheep  or  other  animal 
serum  is  not  available,  one  may  use  antistreptococcic  serum.  Ten  c.  c.  of 
normal  human  serum,  when  it  can  be  had,  is  a  safer  and  more  efficacious 
remedy.  Direct  transfusion  of  human  blood  has  been  successfully  used 
in  the  treatment  of  the  hemorrhagic  diseases  of  infancy  and  childhood. 
These  remedies  may  not  permanently  remove  the  cause  of  the  disease,  al- 
though they  produce  great  temporary  benefit  by  restoring  the  impaired 
blood  coagulability. 


CHAPTEE    LXVIII 
HODGKIN'S     DISEASE 

Hodgkin's  disease,  also  described  under  the  synonyms  ademe,  lymph- 
adenoma  and  pseudoleukemia,  is  characterized  by  a  progressive,  painless 
enlargement  of  lymph  nodes,  usually  beginning  in  the  neck,  associated 
with  a  progressive  anemia  and  frequently  with  the  formation  of  nodules 
in  the  spleen  and  other  internal  organs. 

Etiology. — Nothing  is  known  of  the  causes  of  this  disease.  Tubercu- 
losis is  not  infrequently  associated  with  it  as  a  secondary  infection.  It 
occurs  most  commonly  in  childhood  and  early  adult  life,  is  not  infre- 
quent in  the  second  and  third  decades,  but  is  comparatively  rare  after 
forty. 

Pathology. — A  symptom-complex  closely  resembling  Hodgkin's  disease 
may  be  presented  by  other  pathological  processes,  such  as  lymphosarcoma, 


DIAGNOSIS  541 

but  the  term  should  l)e  confined  to  a  chronic  inflammatory  process  which 
produces  an  enormous  enlargement  of  lymph  nodes,  and  results  in  the 
deposit  of  lymphatic  nodules  in  the  spleen,  liver,  subcutaneous  tissues, 
and  other  parts  of  the  body.  The  exciting  cause  of  this  progressive 
chronic  inflammatory  process  is  not  known,  but  the  microscopical  changes 
produced  are  the  same  as  in  other  chronic  inflammations. 

Symptomatology. — General  Symptoms. — Enlargement  of  lymph  nodes 
beginning,  as  a  rule,  in  the  posterior  triangle  of  the  neck,  is  the  charac- 
teristic symptom.  It  may  rarely  begin  in  the  inguinal,  axillary,  medi- 
astinal, or  other  lymph  glands.  The  enlargement  of  these  nodes  produces 
painless  tumor  masses  which  spread  by  continuity  to  neighboring  glands 
on  the  same  or  opposite  sides  of  the  neck  or  into  the  mediastinal  or  axillary 
regions,  in  this  way  producing  enormous  tumor  masses,  which  are  firm, 
hard  and  nodular,  but  are  freely  movable,  and  show  no  tendency  to  sup- 
puration. The  disease  may  be  uniformly  progressive,  or  there  may  be 
periods  of  apparent  quiescence  followed  by  periods  of  rapid  growth.  As 
it  progresses,  pressure  symptoms  may  result  from  these  large  tumors, 
impinging  on  the  trachea,  bronchi,  blood  vessels,  nerves,  bile  ducts,  ureters 
and  other  tissues.  There  is  progressive  anemia,  weakness,  and  cachexia. 
The  gradually  increasing  dyspnea,  which  may  end  in  strangulation,  is  the 
most  terrible  of  all  these  pressure  symptoms. 

The  spleen  is  moderately  enlarged  in  a  majority  of  the  cases,  and  the 
liver  may  also  be  increased  in  size.  Nodular  masses  in  the  subcutaneous 
tissues  may  occur. 

The  fever  is  very  variable;  afebrile  cases  may  occur;  as  a  rule,  there 
is  a  low  continued  fever,  rarely  rising  above  103°F.,  which  continues  for 
months ;  in  other  instances  it  may  be  intermittent,  and  in  those  cases,  with 
periods  of  apparent  quiescence,  there  may  be  periods  in  which  the  tem- 
perature is  normal,  followed  by  periods  of  severe  pyrexia,  during  which 
there  is  a  rapid  progression  of  the  disease. 

Blood  Changes. — The  only  important  blood  change  which  occurs  in 
this  condition  is  a  simple  secondary  anemia,  caused  by  an  almost  equal 
reduction  in  hemoglobin  and  red  blood  corpuscles.  This  anemia  is 
progressive,  and  as  the  disease  advances  becomes  extreme.  In  the  last 
stages  there  may  be  less  than  30  per  cent,  of  hemoglobin  and  less  than 
2,000,000  red  blood  corpuscles  per  c.  mm.  The  leukocyte  picture  is  prac- 
tically normal;  there  may,  however,  be  a  slight  leukocytosis  of  15,000 
or  20,000. 

Diagnosis. — In  lymphosarcoma  the  disease  does  not  confine  itself  to 
the  lymphatic  glands,  so  that  the  tumor  mass  is  softer  and  the  nodules 
less  clearly  defined  than  in  Hodgkin's  disease.  When  in  doubt,  a  micro- 
scopical examination  of  one  of  the  superficial  lymph  nodes  removed  from 
the  mass  will  definitely  determine  the  character  of  the  growth. 

Tuberculosis  may  rarely  produce  large,  painless  lymphatic  tumors  of 
the  neck,  which  may  grow  in  size  and  extend  from  node  to  node  over  a 
period  of  months,  without  showing  any  tendency  to  break  down.     These 


542  simplp:  adenitis 

cases  may  be  confused  with  Hodgkin's  disease,  l)ut,  as  a  rule,  the  diagnosis 
can  be  made  by  the  tuberculin  skin  reaction,  and  by  other  symptoms  of 
lymph-node  tuberculosis.  The  examination  of  a  superficial  lymph  node 
removed  from  the  mass  will  establish  the  diagnosis. 

From  leukemia  and  secondary  anemias  with  splenic  enlargement  this 
disease  may  be  differentiated  by  the  blood  examination.  The  so-called 
pseudoleukemia  of  infancy  bears  no  resemblance  whatever  ^^o  this  disease. 

Prognosis.  — The  disease  is  probably  always  fatal,  usually  terminating 
within  two  years,  but  patients  may  live  for  four  or  even  five  years.  Death 
may  occur  from  tuberculosis,  secondary  anemia,  septic  or  other  infections, 
or  from  the  ])ressure  of  the  tumor  masses  on  vital  structures. 

Treatment. — There  is  no  treatment  that  exerts  any  curative  influ- 
ence. The  removal  of  the  tumor  masses  by  surgical  measures  may  give 
temporary  relief  from  pressure  symptoms,  but  has  no  influence  on  the  prog- 
ress of  the  disease.  Arsenic  has  been  in  general  use  for  a  long  time  in 
the  treatment  of  this  condition.  It  should  be  given  in  large  doses  over 
long  periods  of  time,  and  the  consensus  of  opinion  is  that  it  some- 
times diminishes  the  size  of  the  tumors,  and  frequently  causes  a  temporary 
cessation  in  their  growth.  It  exerts  no  curative  action,  and  probably  has 
little  influence  in  prolonging  life. 

The  X-ray,  at  the  present  time,  is  the  remedy  most  in  vogue  in  the 
treatment  of  this  condition.  Under  its  use  the  large  lymphoid  tumors  may 
diminish  in  size,  and  in  some  cases  almost  disappear.  When  the  treat- 
ment is  discontinued,  however,  the  tumor  masses  reappear.  This  treat- 
ment, therefore,  has  no  curative  influence.  It  is  believed,  however,  that 
if  the  X-ray  is  used  to  reduce  the  size  of  these  lymphoid  masses  when  they 
become  large  or  exert  uncomfortable  or  dangerous  pressure  symptoms,  the 
life  of  the  patient  may  be  made  more  comfortable,  and  may,  perhaps,  be 
prolonged. 


CHAPTER   LXIX 

SIMPLE    ADENITIS 

Simple  adenitis  is  an  inflammation  of  lymph  nodes  not  produced  by 
tuberculosis  or  syphilis.  It  is  not  a  distinct  disease,  but  a  secondary 
condition  due  to  infection  with  pathogenic  microorganisms,  commonly 
the  pyogenic  cocci,  which  have  found  their  way  from  nearby  inflammatory 
processes  in  direct  communication  with  the  infected  nodes.  The  pyogenic 
infection  thus  produced  results  in  an  acute  inflammation  and  general  hy- 
perplasia of  the  gland  tissue,  which  may  subside  without  suppuration, 
but  which,  especially  in  infancy,  very  commonly  results  in  the  breaking 
down  of  the  lymph  nodes,  and  more  or  less  involvement  of  the  surround- 
ing cellular  tissue,  with  the  final  discharge  of  the  abscess  through  the 
skin  or  into  some  cavity  of  the  body. 


SYMPTOMATOLOGY  543 

The  deep  cervical  lymph  nodes  are  by  far  the  most  commouly  affected, 
since  they  are  in  direct  communication  with  the  mucous  membranes  of  the 
pharynx,  nose,  throat  and  mouth,  so  commonly  the  sites  of  disease  in 
the  child.  These  glands  become  affected  in  tonsillitis,  pharyngitis,  in- 
flammation of  the  adenoids  and  rhinitis.  The  submaxillary  glands  are  en- 
larged in  stomatitis  and  ulcerated  teeth. 

The  superficial  cervical  l}Tnph  nodes  are  commonly  enlarged  from 
eczema  of  the  scalp  and  face,  or  from  infected  wounds  of  these  regions. 

Simple  adenitis  of  other  lymph  nodes  of  the  body  is  less  common. 
The  inguinal  nodes  may  be  affected  from  vulvovaginitis  in  infancy  and 
from  other  local  inflammatory  processes  in  that  region.  The  axillary 
lymph  nodes  are  commonly  inflamed  as  the  result  of  vaccination,  and  may 
be  enlarged  from  other  infected  wounds  of  the  upper  portion  of  the  arms. 
Adenitis  of  the  bronchial  lymph  nodes  is  associated  with  disease  of  the 
lungs  and  smaller  bronchi,  and  the  deep-seated  abdominal  lymph  nodes 
may  become  affected  in  gastroenteritis  and  other  diseases  of  the  enteric 
canal.  Certain  of  the  acilte  infections,  especially  influenza,  scarlet  fever, 
diphtheria,  and  measles,  are  almost  always  associated  with  more  or  less 
enlargement  of  lymph  nodes.  The  adenitis,  however,  which  is  produced 
by  the  acute  infections  and  by  disease  of  the  lungs  and  gastroenteric  canal, 
as  well  as  that  which  results  from  tuberculosis  and  syphilis,  is  discussed 
in  connection  with  these  diseases.  It  only  remains,  therefore,  for  us  to 
call  attention  very  briefly  here  to  the  fact  that  simple  adenitis,  especially  of 
the  cervical  glands  and  more  rarely  of  the  inguinal  and  axillary  glands, 
occurs  in  young  children,  as  the  result  of  some  simple  nearby  inflamma- 
tory process,  and  that  the  adenitis  in  these  cases  may  be  so  severe  that 
the  causative  condition  may  almost  be  lost  sight  of  in  the  S}Tnptom  group 
that  follows. 

Age  is  a  most  important  predisposing  factor  of  simple  adenitis.  The 
great  majority  of  the  cases  occur  under  two  years  of  age.  The  younger 
the  child  the  greater  the  probability  that  the  resulting  inflammation  will 
end  in  suppuration. 

Symptomatology. — The  enlarged  lymph  nodes  are  readily  seen  and 
felt.  They  appear  as  hard,  painful,  tender  masses,  round  or  oblong  in 
shape,  in  the  subcutaneous  tissues  or  beneath  the  superficial  muscles. 
Xeighboring  nodes  may  be  so  agglutinated  by  the  accompanying  cellulitis 
that  a  large  tumor  mass  may  form,  in  which  the  individual  nodes  may  be 
lost.  Fever  is  present  during  the  acute  stage  and  lymphocytosis  develops. 
As  the  inflammation  proceeds  the  overlying  skin  becomes  red,  and  if  sup- 
puration occurs,  as  it  frequently  does  in  infancy,  a  softening  of  the  in- 
flamed glands  may  be  felt.  The  abscess  points  and  flnally  breaks  through 
the  skin,  and  with  the  discharge  of  pus  the  inflammation  quickly  subsides 
and  the  wound  heals.  In  the  great  majority  of  cases,  and  this  is  espe- 
cially true  in  children  over  two  years  of  age,  the  tender,  tumor-like  mass, 
large  or  small,  after  the  second  or  third  week  gradually  diminishes  in 
size,  loses  its  tenderness,  and  the  individual  nodes  which  were  formerly 
86 


544  SIMPLE   ADENITIS 

lost  in  the  tumor  mass  may  now  be  made  out.  In  the  majority  of  in- 
stances these  glandular  swellings  gradually  disappear,  so  that  a  return  to 
normal  conditions  may  be  expected  in  from  four  to  six  weeks.  If,  how- 
ever, the  source  of  irritation  which  originally  caused  the  lymph  node  en- 
largement continues,  a  simple  chronic  adenitis  may  result.  In  these 
cases  the  lymph  nodes  may  remain  enlarged  for  many  months,  but  the  symp- 
toms are  much  less  pronounced  than  in  the  acute  form  above  described. 

In  simple  bronchial  and  abdominal  adenitis  the  diagnosis  may  be  con- 
firmed by  radiographs  and  by  the  same  physical  signs,  which  have  been 
detailed  in  the  chapter  on  tuberculosis. 

Diagnosis. — The'  diagnosis  of  syphilitic  and  tuberculous  adenitis  has 
been  carefully  considered  elsewhere,  and  if  these  symptom  groups  are  kept 
in  mind  there  should  be  no  difficulty  in  making  a  differential  diagnosis 
of  simple  adenitis.  It  may  be  noted  here,  however,  that  the  presence  of 
a  local  exciting  cause,  such  as  disease  of  the  mucous  membranes  of  the 
nose,  mouth  or  throat,  vaccination  or  vulvovaginitis,  may  speak  in  favor 
of  a  simple  adenitis,  and  also  that,  under  two  years  of  age,  simple  adenitis 
is  much  more  common  than  tuberculous  adenitis,  and  much  less  common 
after  this  period  of  life.  The  diagnosis,  however,  is  usually  made  by  ex- 
cluding tuberculosis  and  syphilis  by  reason  of  the  absence  of  the  charac- 
teristic symptom-complexes  of  these  diseases. 

Treatment. — In  every  instance  the  cause  of  the  adenitis  should  be 
sought  and  treated.  Most  of  these  cases  are  dependent  upon  diseases  of 
the  lymphoid  tissues  of  the  pharynx.  The  most  important  part  of  the 
treatment,  in  such  cases,  is  the  careful  treatment  of  all  catarrhal  conditions 
of  the  nasopharynx.  Inunctions  of  unguentum  Crede  and  guaiacol  ^  into 
the  tissues  surrounding  the  enlarged  lymph  nodes  are  of  great  value  and 
should  be  resorted  to  in  all  severe  cases.  The  technique  of  this  treatment 
is  given  in  the  chapter  on  Scarlet  Fever.  Cold  compresses  are  of  value 
in  many  cases.  When  abscess  formation  can  be  definitely  made  out,  an 
incision  should  be  made  and  the  pus  evacuated.  In  subacute  and  chronic 
cases,  where  the  glands  remain  large  and  tender  with  no  tendency  to  sup- 
puration, the  application  of  flexible  collodium,  as  recommended  by  Forch- 
heimer,  by  exerting  a  steady  pressure  upon  these  glands,  promotes  their 
absorption.  Iron  and  iodin  tonics  are  of  value.  In  older  children  the 
freshly  prepared  syrup  of  the  iodid  of  iron  is  followed  by  good  results. 
In  all  cases  fresh  air  and  properly  selected  food  are  almost  of  as  much 
value  as  they  are  in  the  treatment  of  tuberculous  adenitis. 

^See  Tuberculosis. 


ANATOMY    AND    PATHOLOGY  545 

CHAPTER    LXX 
STATUS   LYMPHATICUS 

Status  lymphaticus  is  characterized  by  a  hyperplastic  enlargement  of 
the  thymus  gland  and  other  lymphoid  structures.  This  lymphatic  hyper- 
plasia is  commonly  associated  with  a  lowered  vitality,  a  chloranemia,  and 
a  well-marked  dyspnea,  which  may  be  aggravated  into  pronounced  asth- 
matic attacks  or  end  in  sudden  death. 

Anatomy  and  Pathology. — The  thymus  is  a  ductless  gland  composed 
of  lymphoid  tissues,  holding  remnants  of  the  epithelial  structures  which  in 
early  life  predominated  in  its  makeup.  It  consists  of  two  lobes  joined 
together  in  the  median  line.  It  is  situated  behind  the  upper  portion  of 
the  sternum  occupying  the  superior  strait  of  the  anterior  mediastinum. 
Below,  it  rests  upon  the  pericardium  and  extends  upward  over  the  great 
vessels  of  the  heart  into  the  neck,  resting  on  the  trachea  as  far  up  as  the 
thyroid  gland.  Laterally  it  is  in  contact  with  the  vagi,  the  phrenic 
nerves,  the  innominate  and  common  carotid  arteries.  Its  association, 
however,  with  the  trachea  in  the  narrowest  portion  of  the  chest,  between 
the  manubrium  sterni  and  the  spinal  column,  is  of  special  pathological  im- 
portance, since  enlargement  of  the  gland  in  this  narrow  confined  space 
must  necessarily  contract  the  lumen  of  the  trachea.  It  is  relatively  large 
in  infancy  and  early  childhood,  and  slowly  increases  in  size  up  to  the 
fifteenth  year,  after  which  regressive  changes  slowly  take  place  which 
diminish  its  size  and  physiological  efficacy.  The  size  of  this  gland  varies 
greatly  in  different  individuals  of  the  same  age.  Warthin  accepts  7  grams 
as  the  average  weight  in  the  new-born,  and  15  grams  as  evidence  of  a 
hyperplastic  condition  of  this  organ.  It  is  generally  believed  that  the  thy- 
mus furnishes  an  internal  secretion  which  exerts  an  important  influence 
on  nutritional  processes,  and  especially,  as  the  writer  believes,  on  the  func- 
tional efficiency  of  all  lymphoid  tissues.  Its  period  of  greatest  functional 
activitv  is  during  fetal  life  and  early  childhood.  This  function  diminishes 
most  rapidly  after  the  fifteenth  year,  but  probably  remains  more  or  less 
active  throughout  life.  Svchla  offered  the  theory  that  hyperthymization 
was  the  important  cause  of  status  lymphaticus. 

The  most  important  pathological  condition  in  status  lymphaticus  is 
a  true  hyperplasia  of  lymphoid  tissues,  most  marked  in  the  thj-mus  gland. 
This  gland  may  be  greatly  enlarged,  weighing  forty  or  fifty  grams, 
and,  according  to  Warthin,  there  may  also  be  a  congestion  or  edema  which 
further  increases  its  size  and  leads  to  pressure  upon  the  trachea  and 
other  important  structures  held  in  the  narrow,  closely  confined  and  un- 
yielding space  beneath  the  upper  part  of  the  sternum.  The  enlargement 
of  the  spleen,  tonsils,  adenoids,  lymphatic  glands,  and  lymphoid  tissue  in 
general,  so  commonly  associated  with  the  enlarged  thymus,  is  also  hyper- 
plastic in  character.    There  is  hypoplasia  of  the  general  arterial  system; 


546  STATUS  LYMPHATICUS 

marked  blood  changes  occur  and  the  heart  muscle  may  be  weak  and  dilated. 
Eachitic  and  syphilitic  changes  are  present  in  some  of  tlie  cases. 

There  is  no  doubt  that  enlargement  of  tlie  thymus  may  by  compress- 
ing the  trachea  produce  dyspnea  and  violent  attacks  of  asthma.  This  is 
proven  by  the  fact  that  these  symptoms  may  be  relieved  either  l)y  extirpat- 
ing the  enlarged  thymus,  or  by  inserting  into  the  trachea  beyond  the  point 
of  constriction  a  long  intubation  tube.  It  does  not  follow,  however,  that 
these  symptoms  may  not  in  otlier  cases  be  produced  by  pressure  on  other 
tissues  or  by  toxins,  or  by  hyperthymization  (Svchla). 

Symptomatology.  ■ — The  most  important  symptom  and  the  one  that  usu- 
ally calls  attention  to  the  condition  is  the  dyspnea,  which  may  vary  in 
severity  from  a  mild  stridor  to  a  violent  attack  of  asthma  terminating  in 
the  death  of  the  infant.  A  severe  spasmodic  cough  almost  always  accom- 
panies this  stridor.  The  cough  may  produce  vomiting,  be  associated  with 
cyanosis  and  greatly  aggravate  the  dyspnea,  precipitating  at  times  severe 
asthmatic  attacks. 

Thymic  asthma  is  an  exaggeration  of  the  thymic  dyspnea  or  stridor. 
The  first  difficulty  in  breathing  associated  with  an  irritable  or  spasmodic 
cough  usually  makes  its  appearance  in  early  infancy,  sometimes  soon  after 
birth.  These  symptoms  may  disappear  and  reappear  from  time  to  time, 
perhaps  gradually  increasing  in  severity,  over  a  period  of  months  and  even 
years,  until  the  disease  becomes  so  advanced  that  asthmatic  attacks  are 
precipitated  by  indigestion,  influenza,  slight  catarrhal  conditions  in  the 
nose  or  bronchial  tubes,  or  by  any  pathological  condition  which  irritates 
lymphoid  tissues.  In  severe  cases,  throwing  the  head  backward  may  pro- 
duce a  violent  asthmatic  attack.  As  the  disease  progresses  these  asthmatic 
attacks  become  more  violent  and  recur  without  apparent  cause,  severe 
dyspnea  being  almost  continuous.  In  these  cases  marked  cyanosis  and 
temporary  suspension  of  breathing  may  threaten  suffocation;  sudden  death 
may  occur. 

Sudden  deaths  in  infanc}'^  from  slight  or  unknown  causes  are  commonly 
due  to  the  status  lymphaticus.  Deaths  from  slight  surgical  operations, 
such  as  the  removal  of  adenoids,  and  circumcision,  and  from  slight  in- 
juries or  from  sudden  shock,  such  as  coming  in  contact  with  cold  water, 
as  in  bathing,  may  be  of  this  character.  In  some  instances  death  may  oc- 
cur without  apparent  cause;  the  child  may  be  playing  about  when  sud- 
denly it  becomes  cyanotic,  slightly  convulsed,  and  quickly  dies  of  respira- 
tory failure,  or  it  may  be  found  dead  in  bed.  These  latter  cases  no  doubt 
include  some  of  those  thought  to  be  due  to  "overlaying."  The  exact 
modus  operandi  of  these  deaths  is  not  understood,  and  just  what  role 
hyperthymization  and  pressure  on  the  trachea,  the  pharynx,  or  pneumo- 
gastrics  play  is  yet  to  be  decided.  In  perhaps  most  of  these  cases  a  diag- 
nosis might  have  been  made  if  the  disease  had  been  suspected  and  the 
patient  subjected  to  a  careful  examination  during  life.  It  should  also  be 
remembered  in  this  connection  that  sudden  death  in  infants  may  occa- 
sionally occur  from  causes  entirely  apart  from  the  status  lymphaticus. 


SYMPTOMATOLOGY  547 

Laryngeal  spasm  and  acute  pulmonary  congestion  are  among  such  causes. 

Sudden  deatlis  from  anesthesia  in  infancy  and  childhood  are  almost 
always  due  to  this  cause,  and  the  diagnosis  in  most  of  these  cases  is  made 
on  the  ])ost-niortem  table,  by  the  finding  of  an  enlarged  thymus,  a  weak 
and  dilated  heart  muscle,  and  perhaps  other  signs  of  the  status  lymphaticus. 
Chloroform  is  considered  more  dangerous  than  ether  in  these  cases.  When 
the  importance  of  this  subject  is  fully  realized  by  the  surgeon  and  gen- 
eral practitioner,  and  every  child  before  being  given  an  anesthetic  is  care- 
fully examined  for  evidences  of  the  status  lymphaticus,  then  death  from 
anesthesia  in  childhood  will  be  extremely  rare. 

Enlargement  of  the  Thymus. — If  attention  is  directed  to  the  possible 
presence  of  this  condition  by  an  unexplained  chronic  dyspnea  or  general 
enlargement  of  lymphoid  tissues,  enlargement  of  the  thymus,  which  is  the 
most  characteristic  sign  of  this  disease,  may  be  demonstrated  by  physical 
examination.  Blumenreich  says  that  the  dullness  on  percussion  produced 
by  the  normal  thymus  gland  is  in  the  shape  of  a  triangle,  whose  base  is  a 
line  drawn  between  the  sternoclavicular  joints,  and  whose  apex  is  the 
midsternal  line  on  a  level  with  the  second  rib.  This  triangle,  however, 
inclines  a  little  to  the  left  of  the  sternum  at  its  upper  margin.  When 
the  thymus  gland  is  enlarged,  this  triangle  of  dullness  is  extended  in  all 
directions,  but  especially  to  the  left  of  the  sternum,  and  below  the  clavicle. 
Careful  percussion  will,  in  the  great  majority  of  cases,  demonstrate  en- 
largement of  the  thymus.  Boggs  says  the  lower  border  of  thymic  dullness 
moves  upward  when  the  head  is  thrown  back.  The  enlarged  gland  may 
sometimes  be  felt  in  the  suprasternal  fossa. 

Eadiography  is  one  of  the  methods  of  demonstrating  an  enlarged  thy- 
mus. The  radiograph  shows  the  shadow  of  the  thymus  as  continuous  with 
the  heart  shadow  extending  up  on  both  sides  of  the  sternum  into  the  neck. 

The  spleen,  lymph  nodes,  tonsils,  pharyngeal  adenoids  and  follicles 
at  the  base  of  the  tongue  are  commonly  enlarged.  Tumor  masses  in  the 
neck  or  in  the  abdomen  may  be  produced  by  the  agglutination  of  large 
lymph  nodes.    Itching  of  the  skin  is  a  common  symptom. 

A  blood  examination  reveals  a  well-marked  chloranemia,  the  hemo- 
globin being  markedly  reduced,  the  red  corpuscles  normal  in  number,  but 
showing  many  normoblasts  and  poikilocytes.  A  marked  leukocytosis  is 
commonly  present,  and  the  differential  count  shows  a  great  relative  in- 
crease in  the  number  of  lymphocytes.  In  one  of  my  cases  the  blood  ex- 
amination was  as  follows :  Hemoglobin,  t>5  to  70  per  cent. ;  red  corpuscles, 
fresh  preparation,  showed  considerable  poikilocytosis,  a  few  "ameboid" 
micropoikilocytes,  and,  on  the  whole,  the  red  cells  were  smaller  than  nor- 
mal ;  the  stained  preparation  showed  6  normoblasts  to  500  whites  counted ; 
white  corpuscles,  24,600;  red  corpuscles,  5,881,250;  color  index,  0.58. 
Differential  count:  polymorphonuclear  neutrophiles,  25.6  per  cent.;  small 
lymphocytes,  61.8  per  cent. ;  large  lymphocytes,  2.6  per  cent. ;  large  mono- 
nuclear leukocytes,  8.4  per  cent.;  eosinophiles,  0.6  per  cent.;  mast  cells, 
1  per  cent. 


548  STATUS  LYMPHATICUS 

The  child  is  usually  fat,  flabby,  and  to  the  naked  eye  presents  a  well- 
marked  anemia  bordering  on  pallor.  The  heart  is  usually  rapid  and  irri- 
table, and  may  be  acutely  dilated.  These  children  are  non-resistant,  mal- 
nourished, neurotic,  predisposed  to  convulsive  disorders,  and  frequently 
succumb  to  the  acute  infections. 

In  rare  instances  the  thymus  gland  alone,  of  all  the  lymphoid  tissues 
of  the  body,  suffers  hyperplasia.  In  such  cases  the  symptom-complex  of 
the  status  lymphaticus  as  above  given  is  not  complete,  the  patient  suffer- 
ing only  from  those  symptoms  produced  by  an  enlarged  thymus. 

Progfnosis. — This  condition  is  fraught  with  many  dangers.  Many 
of  these  patients  die  from  intercurrent  diseases  such  as  the  acute  infec- 
tions. Many  of  the  deaths  from  anesthesia  and  many  of  the  sudden  deaths, 
especially  in  childhood,  from  slight  or  unascertainable  causes  are  due  to 
this  condition.  The  brilliant  results,  however,  which  have  recently  been 
obtained  by  surgery  and  by  the  use  of  the  X-rays  promise  to  greatly  dim- 
inish the  mortality  from  this  disease.  It  should  also  be  remembered  that 
as  time  goes  on  the  natural  physiological  atrophy  of  the  thymus  gland 
tends  to  a  spontaneous  cure,  so  that  in  the  milder  cases  the  disease  is 
gradually  outgrown. 

Treatment. — It  is  my  belief  that  in  infants  and  young  children  Eoxt- 
GEN  RAYS  act  Specifically  in  the  control  of  the  dyspnea  and  certain  other 
important  symptoms  of  status  lymphaticus,  and  that  when  this  method  of 
treatment  is  judiciously  used  and  assisted  by  other  therapeutic  measures, 
the  symptoms  of  this  disease  may  be  controlled  until  time,  which  brings 
about  gradual  diminution  in  the  size  and  function  of  the  thymus,  completes 
the  cure. 

When  the  enlarged  thymus  gland  in  a  case  of  status  lymphaticus  is 
exposed  to  the  influence  of  the  X-rays,  we  have,  as  a  result  of  this  treat- 
ment ^ : 

"1.  Decrease  in  size  of  the  hyperplastic  thymus,  with  the  disappearance 
of  the  cough,  stridor,  and  asthma. 

"2.    Decrease  in  size  of  the  enlarged  spleen  and  lymph  nodes. 

"3.    Stimulation  of  the  physical  and  intellectual  growth  of  the  patient. 

"4.  Eapid  disappearance  of  the  marked  lymphocytosis  which  character- 
izes this  disease. 

"5.    Control  of  the  excessive  physiological  action  of  the  thymus  gland. 

"The  slight  return  of  the  symptoms,  stridor,  cough,  etc.,  at  intervals  of 
three  or  four  months,  in  one  of  my  cases,  and  the  quick  control  of  these 
symptoms  by  one  or  two  exposures  to  the  X-rays  indicate  that  the  gradual 
regeneration  of  the  thymus  following  the  X-ray  treatment  may  be  accom- 
panied by  a  gradual  reproduction  of  the  same  pathological  conditions, 
hypersecretion,  etc.,  which  were  present  before  the  treatment  was  begun. 
Since  the  above  remarkable  results  are  brought  about  by  the  action  of  the 
X-rays  on  the  thymus  gland,  it  would  appear  that  the  excessive  physiolog- 
ical activity  of  the  thymus  gland  bears  the  same  relationship  to  status 
^The  author  in  The  American  Journal  of  Medical  Sciences,  October,  1910. 


TEEATMENT  549 

lymphaticus  that  excessive  activity  of  the  thyroid  gland  bears  to  exophthal- 
mic goiter.  One  seems  justified  in  inferring  from  the  above  facts  that 
the  exciting  cause  of  true  status  lymphaticus  acts  primarily  on  the  thymus 
gland,  commonly  producing  marked  hyperplasia  of  this  organ  with  an  in- 
crease in  or  perversion  of  its  internal  secretion,  and  that  this  increased 
or  perverted  secretion  is  responsible  for  the  general  hyperplasia  of  lymphoid 
tissues,  the  lymphocytosis,  and  general  feebleness  of  constitution  which 
occur  in  this  disease.  This  inference  seems  justified  by  the  facts  above 
noted,  that  the  general  hyperplasia  of  lymphoid  structures,  as  well  as  all 
of  the  other  symptoms  of  status  lymphaticus,  disappear  when  the  X-rays 
reduce  the  thymus  to  normal  size  and,  perhaps  of  more  importance,  to  nor- 
mal functional  activity." 

Alfred  Friedlander  ^  demonstrated  experimentally  that  any  degree  of 
fibrosis  of  the  thymus  gland  could  be  produced  by  the  action  of  the  X-ray 
on  this  gland  and  that  a  thymus  thus  partially  involuted  is  capable  of 
regeneration. 

In  1907  Alfred  Friedlander  reported  a  case  of  status  lymphaticus 
with  marked  enlargement  of  the  thymus  and  persistent  stridor.  Heinecke 
(quoted  by  Friedlander)  demonstrated  the  selective  action  of  Kontgen 
rays  on  lymphoid  tissues,  including  the  thymus,  and  showed  that  under 
their  action  marked  changes  occurred  in  these  tissues  with  a  reduction  in 
their  size.  In  a  case  of  status  lymphaticus  Hochsinger,  by  repeated  ex- 
posures, decreased  the  area  of  thymic  dullness  and  greatly  improved  the 
stridor.  In  the  last  few  years  a  number  of  successful  cases  have  been  re- 
ported. 

The  technique  of  this  treatment  in  my  cases  was  as  follows :  The  tube 
for  the  passage  of  the  X-rays  had  an  aperture  two  inches  in  diameter, 
was  enclosed  in  a  ray-proof  shield,  and  every  portion  of  the  body  of  the 
child,  except  the  region  of  the  thymus,  was  protected  from  the  rays.  In- 
jury to  the  skin  was  guarded  against  by  filtering  the  rays  through  a 
piece  of  sole  leather.  The  distance  of  the  tube  from  the  skin  was  ten 
inches  and  the  amount  of  current  used  1  milliampere.  The  character  of 
the  tube  was  high  vacuum  and  well  seasoned  penetration  (Walter  6).  The 
exposure  was  directly  over  the  thymus  gland  both  anteriorly  and  posterior- 
ly; the  time  of  exposure  in  beginning  the  treatments  was  three  minutes; 
at  the  close  of  the  treatments  in  the  fifth  or  sixth  week  it  was  eight  min- 
utes; from  fourteen  to  eighteen  treatments  were  given.  During  the  first 
week  from  four  to  six  treatments  were  given  of  three  minutes  each  both 
anteriorly  and  posteriorly ;  during  the  second  week  three  treatments  of  four 
minutes  each  anteriorly  and  posteriorly ;  during  the  third  week  two  or  three 
treatments  of  six  minutes  each  anteriorly  and  posteriorly ;  during  the  fourth 
week  no  treatments  were  given ;  during  the  fifth  and  sixth  weeks  two  treat- 
ments of  eight  minutes  each. 

Under  this  treatment  the  enlargement  of  the  thymus,  spleen,  and 
other   lymphoid   tissues   was   gradually   reduced,   the   dyspnea   and   cough 

*  Archives  of  Pediatrics,  October,  1911. 


550  STATUS  LYMPHATICUS 

slowly  improved;  the  lymphocytosis  disappeared,  and,  although  tlie  chlor- 
anemia  commonly  remained,  there  was  great  improvement  in  the  physical 
condition  of  the  patient. 

No  definite  rules  can  at  present  be  given  to  govern  the  administration 
of  the  Eontgen  rays  in  the  treatment  of  an  individual  case.  One  may  say, 
however,  that  these  treatments  should  be  administered  as  above  outlined 
over  a  period  of  from  four  to  six  weeks,  provided  the  patient  continues  to 
improve.  It  is  not  wise,  however,  to  continue  the  X-ray  treatment  after 
the  lymphocytosis  has  disappeared,  even  though  there  may  remain  a  slight 
amount  of  dyspnea  and  some  cough,  since  these  symptoms,  as  a  rule,  en- 
tirely disappear  within  a  few  weeks  after  the  discontinuance  of  the  treat- 
ment. The  prolonged  use  of  the  X-rays  in  these  cases  may  aggravate  the 
chloranemia  and  otherwise  interfere  with  nutritional  processes.  In  the 
first  course  of  X-ray  treatments  it  is  better  to  make  the  mistake  of  stop- 
ping the  treatment  too  early  than  of  continuing  it  too  long.  If  it  be  found 
later,  after  an  interval  of  some  months,  that  the  symptoms  of  status  lymph- 
aticus  are  returning,  two  or  three  treatments  with  the  rays  at  intervals  of  a 
few  days  will  again  bring  these  symptoms  under  control.  In  one  of  my 
cases  it  was  necessary  to  give  a  number  of  X-ray  treatments  at  intervals  of 
three  or  four  months  over  a  period  covering  a  year  and  a  half  from  the 
time  the  first  series  of  treatments  were  given. 

As  an  adjunct  to  the  X-ray  treatment,  fresh  air,  nutritious  and 
easily  digested  food,  and  some  preparation  of  easily  assimilated  irox  are 
of  the  very  greatest  importance.  It  is  advisable  early  in  the  case  to  give 
some  preparation  of  organic  iron  preferably  combined  with  malt  extract, 
and  this  should  be  continued  long  after  the  X-ray  treatment  has  been  dis- 
continued, or  until  the  chloranemia  has  entirely  disappeared.  In  one  of 
my  cases  a  very  marked  chloranemia,  which  remained  after  the  discon- 
tinuance of  the  X-ray  treatment,  very  quickly  responded  to  hypodermic 
injections  of  neutral  citrate  of  iron  in  %-grain  doses  given  once  a  day. 

In  the  management  of  a  case  of  status  lymphaticus  it  is  important  to 
remember  that  great  danger  attends  the  giving  of  anesthetics,  and  that 
sudden  shocks  to  the  nervous  system,  such  as  result  from  cold  baths,  may 
endanger  life,  and  that  it  is  important  to  avoid  all  acute  infections,  es- 
pecially those  which  involve  the  respiratory  tract,  since  these  diseases  not 
uncommonly  end  fatally  in  this  class  of  cases. 

The  amount  of  exercise  which  these  patients  take  should  be  carefully 
regulated.  If  marked  dyspnea  or  a  dilated  heart  with  rapid  and  feeble 
heart  action  exists,  exercise  not  only  aggravates  these  symptoms,  but  it  may 
be  even  dangerous  to  life. 

If  syphilis  be  suspected,  antisyphilitic  treatment  should  be  given; 
if  rickets  is  present,  fresh  air,  cod-liver  oil,  and  a  proper  diet  should  be 
prescribed. 

Surgical  Treatment. — The  results  of  thymic  surgery  have  been  un- 
usually brilliant;  five  cases  are  reported  in  which  this  treatment  resulted 
in  a  cure.    All  of  these  cases  were  aggravated  ones,  the  patient  suffering 


DISEASES   OF   THE    SPLEEX:    EXLARGEMENT  551 

from  extreme  dyspnea  and  other  distressing  symptoms  of  status  lymph- 
aticus.  The  operation  consists  in  the  complete  or  partial  removal  of  the 
thymus  gland.  As  a  result  of  experience  it  is  advised  that  in  infants  and 
young  children  only  the  upper  portion  of  the  gland  be  removed,  and  that 
the  lower  portion  be  drawn  up  so  as  to  lift  it  from  its  position  and  hold  it 
by  stitching  to  the  surrounding  tissues.  The  total  removal  of  the  thymus 
gland  in  young  infants  will,  it  is  believed  by  Konig  and  others,  interfere 
with  subsequent  development.  At  the  present  time,  however,  the  indica- 
tions are  that  the  X-ray  treatment  will  supersede  the  surgical  treatment 
of  this  condition. 

CHAPTER    LXXI 
DISEASES    OF    THE     SPLEEN:    ENLAEGEMENT 

In  infancy  the  normal  spleen  varies  in  length  from  4  to  6  or  8  cm.  It 
extends  from  the  mid-axillary  line  backward,  its  upper  border  correspond- 
ing with  the  ninth  and  its  lower  with  the  eleventh  rib. 

Enlargement  of  the  spleen  is  very  common  in  infancy,  and  in  many 
conditions  it  is  of  great  diagnostic  importance.    One  depends  almost  exclu- 


FiG.  83. — Position  in  Palpating  the  Spleen. 

sively  upon  palpation  for  the  diagnosis  of  enlarged  spleen  in  infancy  and 
childhood.  At  this  age  an  enlarged  spleen  can  be  very  readily  felt  be- 
neath the  margin  of  the  ribs  in  the  mid-axillary  line.  This  sign  is  much 
more  common,  much  more  easily  made  out,  and  of  much  more  clinical  sig- 
nificance in  the  child  than  it  is  in  the  adult.  Percussion  may  also  be  util- 
ized in  outlining  this  organ,  but  this  method  is  of  much  gi'eater  value  in  the 
adult  than  it  is  in  the  child.  When  the  spleen  can  be  readily  felt  beneath 
the  margin  of  the  eleventh  rib,  it  is  either  enlarged  or  displaced  downward ; 


552  DISEASES   OF    THE    THYEOID    GLAND 

enlargement  is  very  common,  displacement  very  rare.  The  enlargement 
may  be  so  great  as  to  almost  fill  the  abdominal  cavity;  this  increase  in 
size  occurs  downward  and  toward  the  umbilicus. 

The  clinical  significance  of  an  enlarged  spleen  will  depend  largely  upon 
the  cause,  and  upon  the  symptom  group  with  which  it  is  associated.  In 
malaria,  typhoid  fever,  status  lymphaticus,  leukemia,  pseudoleukemia  of 
infancy,  and  tuberculosis  (abdominal,  intestinal  and  acute  miliary),  a  well- 
marked  enlargement  of  the  spleen  is  usually  present,  and  this  sign  is  of 
great  diagnostic  value  when  associated  with  the  other  symptoms  of  these 
diseases.  A  moderate  enlargement  of  the  spleen,  of  not  so  much  diagnostic 
value,  is  found  in  syphilis,  rickets,  gastroenteritis,  Hodgkin's  disease,  sep- 
sis, amyloid  disease,  chronic  malnutritions,  anemia,  heart  disease,  peri- 
tonitis, Banti's  disease  and  nearly  all  the  acute  infections. 

Enlargement  of  the  spleen  produced  by  or  associated  with  the  above- 
named  conditions  is  most  commonly  due  to  hyperplasia  of  its  lymphoid 
elements.  Passive  congestion  of  the  spleen  may  result  from  heart  disease, 
cirrhosis  of  the  liver,  chronic  peritonitis  and  all  conditions  that  interfere 
with  the  portal  circulation.  Amyloid  disease  may  be  caused  by  suppura- 
tion and  chronic  bone  diseases,  and  is  associated  with  amyloid  disease  in 
other  parts  of  the  body.  Inflammation  of  the  spleen  (splenitis  and  peri- 
splenitis) may  be  produced  by  peritonitis,  syphilis,  tuberculosis  and 
trauma.  Displacement  of  the  spleen  downward  may  be  produced  by 
pleurisy  with  effusion,  or  there  may  be  an  actual  prolapsus.  The  latter 
condition  is  usually  associated  with  a  general  enteroptosis  of  the  stomach, 
liver,  kidneys,  etc. 

Primary  splenomegaly  is  a  rare  form  of  splenic  tumor  due  to  a  hyper- 
plasia of  its  endothelial  cells.  It  occurs  in  early  childhood  and  progresses 
slowly  to  a  fatal  termination,  lasting  for  years.  The  condition  was  first 
described  by  Gaucher  and  later  carefully  studied  by  Yovaird.  The  splenic 
tumor  gradually  increases  in  size  until  it  may  fill  the  abdomen  and  pro- 
duce pressure  symptoms  of  various  kinds.  There  is  marked  simple  anemia, 
and  a  pronounced  hemorrhagic  tendency.  There  may  be  bleedings  from 
the  nose  and  gums  and  subcutaneous  hemorrhages  may  occur. 


CHAPTER    LXXII 

DISEASES    OF    THE    THYEOID    GLAND 

SPORADIC   CRETINISM 

{Infantile  Myxedema) 

There  are  two  varieties  of  cretinism,  endemic  and  sporadic.  Endemic 
cretinism,  or  myxedema,  is  due  to  a  total  or  partial  destruction  of  the 
thyroid  gland  caused  by  congenital  defects  or  disease,  commonly  asso- 
ciated with  a  goiterous  enlargement.    It  is  endemic  in  certain  mountainous 


SPORADIC    CRETINISM  553 

districts  in  Switzerland,  and  is  characterized  by  dwarfishness  of  mind  and 
body  and  by  myxedema  of  the  subcutaneous  tissues. 

Sporadic  cretinism,  the  common  and  only  form  seen  in  this  country, 
is  due  to  an  absence  or  atrophy  of  the  thyroid  gland  usually  congenital, 
and  very  rarely  associated  with  goiterous  enlargement.  In  rare  instances 
myxedema  may  result  from  disease  of  the  thyroid  gland  following  acute 
infections  or  from  the  complete  removal  of  this  gland  by  surgical  opera- 
tions. These  forms  of  myxedema,  occurring  in  infancy,  may  present  a 
clinical  picture  similar  to  that  of  ordinary  congenital  sporadic  cretinism, 
but  these  acquired  myxedematous  conditions  are  so  infrequent  in  the  infant 
that  they  may  for  practical  purposes  be  disregarded.  Sporadic  cretinism 
presents  a  clinical  picture  in  which,  as  a  rule,  both  mental  and  physical 
dwarfishness  are  more  pronounced  than  in  endemic  cretinism  or  myxedema 
acquired  in  childhood. 

Etiology. — The  cause  of  sporadic  cretinism  is  unknown.  Heredity, 
however,  is  an  important  factor.  Cases  may  occur  in  different  genera- 
tions of  a  family,  but  rarely  do  two  cases  occur  in  the  same  immediate 
family. 

Symptomatology. — The  characteristic  symptoms  of  cretinism  usually 
appear  jjefore  the  end  of  the  first  year  of  life;  they  may,  however,  be 
present  as  early  as  the  second  month,  and  in  less  pronounced  cases  may  be 
delayed  to  the  third  or  fourth  year.  Although  the  disease  is  usually  con- 
genital, the  child  at  birth  presents  no  symptoms ;  this  is  perhaps  due  to 
the  fact  that  up  to  the  time  of  birth  the  child  receives  its  thyroid  secre- 
tions from  the  mother,  and  after  birth,  although  there  may  be  a  total  ab- 
sence of  the  thyroid  body,  it  requires  months  to  develop  the  characteristic 
symptoms  which  result  from  the  absence  of  thyroid  secretions.  Because 
of  its  insidious  onset,  it  is  most  important  for  the  physician  not  only  to 
keep  in  mind  the  general  syndrome  of  this  disease,  but  to  be  ever  on  the 
lookout  for  the  early  symptoms  which  announce  its  approach;  an  early 
diagnosis  means  success  in  treatment.  Mental  dullness  is  usually  the  first 
symptom  noted;  the  infant  is  placid,  torpid  and  presents  more  or  less  evi- 
dence of  stupidity  in  failing  to  do  the  things  which  a  normal  child  of  its 
age  would  do.  It  cannot  be  interested  in  toys,  or  be  attracted  by  things 
done  for  its  amusement,  and  not  only  fails  to  use  its  arms  and  legs  in  a 
normal  manner,  but  becomes  more  clumsy  and  less  apt  in  this  particular 
than  it  formerly  was.  This  physical  retrogression  with  an  evident  lack  of 
intellectuality  is  accompanied  by  a  vacant  expression  which  characterizes 
the  face  and  there  slowly  develop  the  characteristic  facies  and  stunted 
development  of  the  whole  body  which  make  the  diagnosis  plain.  The 
head  is  large  in  proportion  to  the  body,  the  forehead  low  and  narrow, 
the  fontanels  are  open  and  may  remain  so  until  the  child  is  eight  or  ten 
years  of  age;  the  face  is  broad,  the  cheeks  heavy,  the  nose  flat  and  wide, 
the  eyes  are  wide  apart  and  the  lids  may  be  puffy,  the  lips  are  thick  and 
prominent,  and  the  tongue,  which  is  broad  and  thick,  protrudes  through 
the  open  mouth;  this  lolling  of  the  tongue  which  may  be  accompanied  by 


554 


DISEASES   OF    THE    THYEOID   GLAXD 


drooling  is  a  very  characteristic  s\Tiiptom.  The  child  teethes  late,  and  tiie 
teeth  are  imperfectly  f<Drmed  and  decay  early.  A  hoarse  gutteral  cry  may 
be  one  of  the  early  symptoms. 

The  hair  is  coarse,  dry  and  sc-anty,  the  eyebrows  are  almost  lacking, 
the  skin  of  the  whole  body  is  pale,  dry  and  cold  to  the  touch.  The  sub- 
cutaneous tissues  are  heavy,  tiiick,  boggy,  and  to  the  touch  are  firm  and 
reastant;  small,  fatty  tumors  are  commonly  present,  especially  in  the  lower 
regions  of  the  neck  and  the  upper  part  of  the  back.  The  neck  is  short 
and  thick  and.  on  examination,  a  depression  is  found  where  the  thyToid 
body  should  be  located.    There  is  a  pronounced  anterior  curvature  of  the 

spine  which  produces  a  hollow  back  and 
accentuates  the  protrusion  of  the  large 
and  pendulous  abdomen.  This  anterior 
curvature  of  the  body  is  very  pronounced 
when  the  child  is  standing,  and  is  exag- 
gerated by  the  large  and  apparently  pro- 
truding buttocks,  giving  this  portion  of 
the  body  a  kangaroo  appearance.  Um- 
bilical hernia  is  common,  the  hips  are 
heavy,  and  the  legs  are  short  and  clumsy. 
These  children,  as  a  rule,  do  not  learn  to 
walk  until  they  are  four  or  five  years  of 
age,  and  then  have  a  peculiar  waddling 
gait,  handling  their  bodies  and  arms  in 
a  slow  and  clumsy  manner.  The  hands 
are  thick,  short  and  spadelike;  the  hy- 
pothenar  eminence  is  especially  promi- 
nent; the  fingers  are  short,  blunt  and 
heavy. 
^^  As  the  child  grows  older  the  dwarfed 

^^^  i   ^v  appearance   of  the   whole   body  becomes 

^^^^  more  pronounced :  a  cretin  of  twenty  may 

■^^  not  be  more  than  four  feet  in  height,  and 

with  this  lack  of  physical  development 
there  is  a  corresponding  lack  of  mental 
development.  It  may  not  be  able  to  speak  and  may  not  have  sufficient 
intelligence  to  avoid  uncleanly  habits  in  urination  and  defecation-  A 
state  of  absolute  idiocy  is  present  in  most  of  these  cases.  Troublesome 
constipation  is  not  an  unusual  symptom;  anemia  is  present,  but  the  blood 
examination  shows  nothing  characteristic.  The  temperature  is  subnormal, 
registering  95  or  96  in  the  rectum.  The  sexual  organs  are  late  in  their 
development. 

Differential  Diagnosis. — There  are  few  diseases  that  present  to  the  eye 
so  repulsive  and  so  characteristic  a  picture  as  cretinism;  when  once  seen 
it  is  rarely,  if  ever,  forgotten.  It  can  scarcely  be  confused  with  any  other 
condition,  except,  periiape,  Mongolian  idiocy.     In  this  condition,  however, 


Fig.  84. — Ttpical   Cbeten;  Aob 
Font  Yeabs. 


SPORADIC    CRETINISM 


555 


the  slanting  eyes  and  the  Mongolian  type  of  face,  the  soft  smooth  skin, 
the  soft,  straight,  normal  hair,  the  small  braehyeephalic  skull,  and  the 
absence  of  swelling  in  the  tongue  and  lips  should  suffice  to  make  the  diag- 
nosis plain.  If  in  doubt,  however,  the  therapeutic  test  will  definitely  dif- 
ferentiate the  two  conditions;  Mongolian  idiocy  does  not  respond  to  the 
thyroid  therapy. 

Thyroid  Insufficiency. — While  the  diagnosis  of  ordinary  cretinism  pre- 
sents but  few  difficulties,  it  should  be  remembered  that  there  are  a  much 
greater  number  of  cases  in  which  there  are  degrees  of  thyroid  insufficiency 
varying  from  a  condition  in  which  the  thyroid  insufficiency  is  so  slight  that 
it  produces  few  or  no  characteristic  symp- 
toms to  the  condition,  above  described, 
of  true  cretinism  in  which  the  thyroid 
gland  is  congenitally  absent  or  atrophied. 
These  cases  of  thyroid  insufficiency  pre- 
sent in  a  modified  form  and  milder  de- 
gree the  s\Tnptoms  of  cretinism.  They 
are  undersized  and  underweight,  are  lack- 
ing to  a  greater  or  less  degree  in  mental 
development,  and  are  grouped  in  the 
schools  with  the  ''backward"  children. 
As  a  rule,  they  have  subnormal  tempera- 
tures. 

Frognosis. — The  earlier  the  diagnosis 
the  better  the  prognosis.  If  treatment  is 
begun  during  the  first  year  of  life,  the 
child's  physical  development  may  be  per- 
fect, and  its  mental  development  will  be 
almost,  but,  perhaps,  not  quite,  normal; 
yet,  on  the  whole,  the  result  in  these 
cases  is  satisfactory,  since  they  may  be- 
come useful  members  of  society,  attain- 
ing a  fair  degree  of  intellectual  develop- 
ment and  acquiring  sufficient  education 
to  enable  them  to  follow  some  useful  avo- 
cation. If  the  treatment  is  begun  later 
in  the  life  of  the  child  the  results,  while  striking,  are  not  so  satisfactory, 
and  even  in  cases  where  the  treatment  is  begun  as  late  as  puberty,  marked 
physical  and  mental  improvement  may  result,  but  these  cases  can  never  be 
benefited  sufficiently  to  make  them  self-supporting.  Untreated  cases  re- 
main hopeless,  repulsive  idiots. 

Treatment.— In  the  whole  range  of  medicine  there  is  no  more  remark- 
able example  of  the  marvelous  curative  effect  of  a  therapeutic  measure  than 
is  furnished  by  the  thyroid  treatment  of  cretinism.  In  this  treatment  we 
have  a  brilliant  example  of  true  specific  medication.  Previous  to  the  dis- 
covery of  the  specific  action  produced  by  feeding  the  thyroid  gland  to 


Fig.  85. — Same  Cretin;  Age 
Twelve,  after  Eigett  Years 
OF  Treatmext. 

She  is  now  fourteen  years  old  and 
is  holding  her  own  in  the  5th 
grade  of  the  Cincinnati  pub- 
lic schools.  The  average  age 
of  the  pupils  of  her  grade  is 
about  four  years  younger. 


556  DISEASES   OF   THE    THYEOID    GLAND 

cretins,  these  patients  were  absolutely  beyond  the  reach  of  medical  treat- 
ment; they  remained  hopeless  and  helpless  imbeciles,  fortunately  dying 
of  some  intercurrent  disease  before  middle  life.  At  the  present  time,  un- 
der thyroid  treatment,  they  are  slowly  transformed  into  comparatively 
normal  individuals.  A  cretin  that  came  to  me  at  the  age  of  four  years, 
and  who  has  been  constantly  under  treatment  for  the  last  eight  years, 
has,  as  shown  by  the  accompanying  photograph,  a  fair  degree  of  physical 
and  mental  development.  At  fourteen  years  of  age  she  is  holding  her 
own  in  the  fifth  grade  of  the  Cincinnati  public  schools.  The  average  age 
of  the  pupils  of  her  grade  is  four  years  younger. 

Desiccated  thyroids  in  tablet  form  are  now  universally  used.  They 
are  put  up  in  five-grain  tablets,  each  containing  one  to  two  grains  of  des- 
iccated thyroids.  Whatever  make  of  tablet  is  selected  for  the  treatment 
of  a  case,  the  same  should  be  continued  throughout.  The  dose  for  an  in- 
fant under  one  year  of  age  is  %  grain  two  or  three  times  a  day;  it  is 
rarely  necessary  to  give  more.  For  children  three  or  four  years  of  age 
the  initial  dose  may  be  1  grain,  and  it  may  be  necessary  to  increase  this 
to  2  grains.  It  is  my  belief  that  much  harm  may  be  done  by  giving  too 
large  doses.  The  most  satisfactory  results  are  obtained  by  the  long-con- 
tinued use  of  small  doses.  If  the  child  fails  to  respond  to  the  above  dosage, 
or  if  the  progress  in  its  physical  and  mental  growth  at  any  time  comes  to 
a  standstill,  then  the  dose  should  be  gradually  and  carefully  increased. 
If  at  any  time  in  increasing  the  dosage  the  child  shows  symptoms  of  thyroid 
intoxication,  the  treatment  is  to  be  discontinued  for  a  '^eek  or  ten  days 
until  these  symptoms  have  entirely  subsided.  Thyroid  intoxication  is  indi- 
cated in  the  young  child  by  pallor,  rapid  heart  action,  general  nervous 
irritability,  and  in  older  children  by  headache;  fatal  syncope  may  occur. 
In  a  case  which  I  saw  in  consultation  over  a  number  of  years,  very  satis- 
factory progress  was  made  with  small  doses  of  desiccated  thyroid.  The 
physician,  however,  yielding  to  the  importunities  of  the  parents,  gradually 
increased  the  dose  until  a  very  severe  thyroid  intoxication  was  produced, 
from  which  the  child  never  recovered,  dying  shortly  afterwards.  In  the 
treatment  of  these  cases,  therefore,  the  physician  must  be  satisfied  with  the 
slow  and  gradual  improvement  which  follows  moderate  size  doses ;  otherwise 
he  may  learn  by  experience  the  important  lesson  that  these  children  can 
be  seriously  injured  by  overdosing  with  thyroid.  I  have  rarely  found  it 
necessary  in  the  treatment  of  any  case  to  give  more  than  6  grains  of  des- 
iccated thyroid  in  a  day,  and  it  has  been  my  experience  that  the  dose  which 
has  been  found  effective  in  the  treatment  of  the  condition  in  the  individual 
child  is  the  dose  that  should  be  continued  ever  afterward  to  prevent  a  re- 
turn of  this  condition.  In  the  cases  that  I  have  had  under  observation 
for  six  or  seven  years  the  treatment  has  never  been  interrupted  in  any 
case  for  more  than  two  or  three  weeks  at  a  time,  and  this,  I  think,  should 
be  the  rule  throughout  life. 

Other  treatment  may,  perhaps,  be  of  little  avail,  yet  it  has  been  my 
custom  in   recent  years  to  use  iodin  and  calcium  in  the  treatment  of 


THYROID    INTOXICATION  657 

cretinism.  The  iodin  may  be  given  in  the  form  of  syrup  of  hydriodic  acid 
in  1/^-  to  1-drachm  doses,  or  as  iodonucleoids  in  1-  or  2-graiu  doses.  Cal- 
cium may  be  used  in  the  form  of  an  elixir  of  the  glycerophosphates  of 
lime  and  soda  in  from  i/^-  to  1-drachni  doses,  or  in  the  soluble  lactate  in  1- 
to  3-grain  doses.  The  iodin  and  calcium  medication  may  alternate,  or 
from  time  to  time  may  be  interrupted.  I  believe  that  by  the  use  of  these 
drugs  better  therapeutic  results  are  obtained  than  by  the  use  of  the 
thyroid  extract  alone.  The  change  in  prescriptions  also  serves  the  excel- 
lent purpose  of  keeping  up  the  interest  of  the  mother  and  patient  in  the 
medical  treatment,  which,  if  confined  to  the  thyroid  alone,  after  a  time 
becomes  monotonous  and  may  lead  the  mother  to  conclude  that,  if  no 
other  medical  treatment  is  to  be  given,  she  can  continue  the  thyroid  treat- 
ment herself  without  medical  supervision. 

THYROID  INTOXICATION 

The  thyroid  gland  is  one  of  the  organs  which  has  its  greatest  func- 
tional activity  during  the  early  years  of  life.  It  furnishes  a  secretion 
which  exercises  such  a  controlling  influence  over  the  body  chemistry  that, 
without  it,  normal  growth  and  development  cannot  be  carried  on.  This 
function  of  the  thyroid  is  so  nicely  adjusted  to  the  needs  of  the  organ- 
ism that,  as  a  rule,  it  furnishes  this  secretion  in  quantity  and  quality 
accurately  adjusted  to  the  purposes  it  is  to  serve.  In  a  few  instances, 
however,  this  gland  is  congenitally  absent ;  in  others  its  functional  capacity 
is  diminished  or  destroyed  by  disease  or  accident;  the  resulting  conditions 
are  known  as  cretinism  and  myxedema. 

On  the  other  hand,  from  an  increased  functional  capacity  of  the  thy- 
roid gland  we  may  have  an  excess  of  its  secretions  poured  into  the  body 
media,  producing  a  well-known  group  of  nervous  symptoms.  This  symp- 
tom group  may  be  produced  experimentally  in  man  by  feeding  excessive 
quantities  of  thyroid.  It  is  sometimes  observed  from  overdosage  in  the 
treatment  of  cretinism,  and  it  may  be  observed  in  exophthalmic  goiter,  the 
symptoms  of  which  are  at  least  in  part  produced  by  thyroid  intoxication. 
This  symptom  group  is  characterized  by  headache,  general  nervous  irri- 
tability, rapid  and  at  times  irregular  heart  action,  pallor,  cyanosis,  great 
bodily  weakness,  and  a  sense  of  precordial  distress.  It  is  my  belief  that 
this  symptom  group  in  a  modified  form  very  commonly  occurs  in  rapidly 
growing  children,  and  while  it  may  be  associated  with  a  slight  enlargement 
of  the  thyroid,  it  is  in  no  way  related  to  disease  of  the  thyroid  gland  or 
to  the  development  of  exophthalmic  goiter,  later  in  life.  It  is  simply  a 
thyroid  intoxication  due  to  the  overaction  of  this  gland.  We  know  that 
thyroid  secretions  increase  the  excitability  and  stimulate  the  growth  and 
functional  development  of  the  nervous  system.  It  seems  very  probable, 
therefore,  that  since  childhood  is  the  period  of  life  when  great  thyroid 
activity  is  an  important  factor  in  producing  the  rapid  growth  and  func- 
tional development  of  the  nervous  system,  it  may,  when  slightly  over- 


558  DISEASES   OF    THE    THYEOTD   GLAN'D 

active,  ao  aUtribie  tbe  menramB  srstem  as  to  prodooe  ftmetional  nerroos 
diaordas.  Itmaj,  and  undoTiMedlT  does,  happen  that  the  amount  of  thr- 
Koid  HWiftwHi  vanes  irith  the  individnal  child,  and  when  the  secretion  is 
eimiiwi  it  wemj  prodoee  too  rapid  growth  and  derelopment  of  the  nervous 
afstem,  aeeoHnpaied  bf  nervoaB  initability,  mental  precocity,  tachycardia, 
hf^Pfh^,  and  aflKT  immua  sjapinms  so  eramnonly  observed  in  the  rapid- 
ly growing  diild.  If  to  this  symptom  gronp  is  added  a  slightly  enlarged 
tibjroid,  tjbe  diagaofiis  of  thyroid  intoYieatiwi  may  be  made. 

Ttrntmeatt — Use  neeo^itioii  of  tlys  eonditMfi  is  impOTtant.  It  is 
tranatory,  and.  afto*  a  time,  Batnre  adjnels  tiie  amonnt  of  thyroid  aecre- 
ikm  more  nicely  to  ihe  -wmsAb  of  the  body,  and  with  this  adjustment  ihe 
xapid  growth  and  neirous  symptoms  disq^iear.  Dunag  tiw  period,  how- 
ever, <rf  tbe  UkjTcid  intoxication  these  children  shonld  be  protected  from 
oveiwoiL.  boHi  mental  and  physieaL  and  in  thdr  home  life  and  amnsements 
ihey  shotild  be  placed  raider  eonditioiis  that  wiQ  not  exaggerate  nervous 
imtalMliiy.  It  maty  be  Beceaory  for  a  time  to  remove  them  frook  ediool 
mad  to  plaee  tbem  mder  ifott  snrronndings,  which  will  in  no  way  ocdte 
tlKir  utifwtt  ajnrtoBL  The  btomids  may  be  of  value,  bnt  ihe  ooal-tar 
pfeparations  are  oraitramdicated  in  tlie  treatment  of  this  condition. 


SECTION  X 
DISEASES  OF  THE  UROGENITAL  SYSTEM 

CHAPTEE    LXXIII 
THE    UBINE 

The  medical  profession  has  long  been  fully  impressed  with  the  necessity 
for  routine  urine  examinations  in  older  children,  so  that  this  secretion  has 
been  studied  quite  as  carefully  in  the  older  child  as  in  the  adult.  Fre- 
quent and  careful  urine  examinations  in  scarlet  fever,  diphtheria,  in- 
fluenza, and  other  infections,  and  especially  in  convulsive  and  other  nerv- 
ous disorders  of  childhood,  have  long  been  recognized  as  of  the  greatest 
importance. 

The  difficulty,  however,  of  obtaining  specimens  of  urine  from  infants 
has  been  a  great  barrier  to  its  systematic  study  both  in  the  well  and  in 
the  sick  baby.  In  recent  years  medical  men  have  come  to  realize,  more  and 
more,  the  necessity  for  routine  urine  examinations  in  the  infant,  and  m^iy 
careful  investigations  have  added  greatly  to  our  knowledge.  These  investi- 
gations have  shown  that  serious  kidney  lesions  are  less  common  in  the  infant 
than  they  are  in  the  child,  but  they  have  also  demonstrated  that  many  here- 
tofore obscure  diseases  of  the  genitourinary  organs  of  the  infant  can  be 
satisfactorily  diagnosed  only  by  an  examination  of  the  urine. 

The  following  methods  have  been  recommended  for  collecting  the  urine 
of  infants:  a  wide  flat  sponge,  or  absorbent  cotton,  may  be  held  over  the 
external  urinary  organs  by  the  diaper,  and  the  urine  squeezed  out  of  these 
following  urination;  a  wide-mouthed  bottle,  or  rubber  pouch,  may  be  fas- 
tened over  the  external  urinary  organs  with  adhesive  plaster,  this  latter 
method  being  more  satisfactory  with  the  male  than  with  the  female  infant. 
Chapin's  infant  urinal,  which  is  one  of  the  best  of  a  number  of  devices  de- 
signed for  this  purpose,  may  be  fastened  over  the  external  genitalia  of  both 
male  and  female  infants.  When  the  emergency  demands  it.  catheterization 
may  be  resorted  to  with  a  small  soft  rubber  catheter — No.  6,  American  scale ; 
but  if  the  physician  has  the  cooperation  of  an  intelligent  nurse,  the  urine 
in  the  great  majority  of  instances  may  be  caught  in  a  suitable  vessel  as  it 
is  expelled  from  the  bladder. 

Quantity  of  XTrine. — The  infant  and  young  child  take  from  four  to  six 
times  more  fluid  per  kilogram  of  weight  than  does  the  adult,  and  pass 
37  559 


560  THE    UEINE 

a  correspondingly  larger  quantity  of  urine.  There  may  be  very  great 
variation  from  hour  to  hour  and  from  day  to  day  in  the  quantity  of  urine; 
the  amount  depending  not  alone  upon  the  number  of  ounces  of  fluid  taken, 
but  also  upon  unexplainable  and  uncontrollable  nervous  influences,  which 
may  markedly  inhibit  the  quantity  one  day,  and  greatly  increase  it  the 
following  day.  These  fluctuations,  especially  in  young  infants,  may  have  no 
special  pathological  significance.  One  may  say  that  from  a  pathologi- 
cal standpoint  the  younger  the  child  the  less  important  are  these  vari- 
ations. In  older  children  they  may  indicate,  as  they  do  in  the  adult,  an 
unstable  and  irritable  condition  of  the  nervous  system,  which  in  the  infant 
is  the  normal  physiological  condition,  but  in  the  older  child  and  adult 
is  pathological  and  commonly  due  to  hereditary  or  nutritional  defects  of  the 
nervous  system.  It  is  important  to  remember  that  suppression  of  urine 
(anuria)  may  occur  in  infants  and  young  children,  and  may  last  over  a 
period  of  twelve  or  even  twenty-four  hours,  without  indicating  a  serious 
pathological  condition;  in  many  such  instances,  the  urinary  secretion  is  re- 
established without  one  being  able  to  ascertain  the  cause  of  the  suppres- 
sion, but  in  older  children  such  marked  functional  disturbances  are  com- 
monly due  to  organic  disease,  although  they  may  be  due  to  such  profound 
functional  nervous  disorders  as  hysteria.  The.  following  table  from  Reusing 
shows  the  remarkable  physiological  variations  which  may  occur  in  the  uri- 
nary secretion  of  the  healthy  infant : 

Minimum  Maximum 

In  the  first  24  hours  after  delivery 2      c.  c.  61  c.  c. 

2nd  day    11      e.  c.  145  c.  c. 

3rd  day    13.3  c.  c.  171  c.  c. 

4th  day    17.5  e.  c.  179  c.  c. 

5th   day    22.5  c.  c.  222  c'.  c. 

6th   day    70      c.  c.  280  c.  e. 

7th   day    93      c.  c.  338  c.  c. 

8th   day    100      c.  c.  331  c.  c. 

The  variability  in  the  daily  quantity  of  urine  in  the  infant  and  young 
child  makes  it  difficult  to  compile  a  table  which  represents  with  accuracy 
the  average  amount  of  urine  passed.  Many  careful  investigations  have 
been  published  giving  widely  varying  results.  The  following  table  from 
Jennings  is  "compiled  from  the  studies  of  Holt,  Churchill,  Morse,  and 
other  observers,"  while  the  carefully  prepared  tables  of  Holt,  referred  to, 
include  the  observations  of  Camerer  and  other  German  and  French  writers : 

Age  '    Amount  in  24  hours     Specific  gravity  Urea 

First    week    3  to  90  c.  c.  1.010  to  1.004 

Third  month    200  c.  c.  1.004  ' '  1.010 

Sixth    month    250  e.  c.  1.006  ' '  1.012 

Ninth  month    300  c.  c.  1.006  ' '  1.012 

Pirst   year    400  e.  c.  1.006  ' '  1.012 

Second  year   450  c.  e.  1.006  ' '  1.012 

Third  year   500  c.  c.  1.006  ' '  1.012 


0.07  to 

0.66 

grams 

1.4    " 

2.3 

5.0 

7.0 

11.0 

12.0 

13.0 

LITHURIA  561 

Age  Amount  in  24  hours        Specific  gravity  Urea. 

Fourth  year   550  c.  c.  1.008  to  1.016  13.5  grams 

Fifth  year    600  c.  c.  1.008  ' '    1.016  14.0 

Sixth   year    650  c.  c.  1.008  "    1.016  15.0 

Seventh  year    700  c.  c.  1.008  "    1.016  16.0 

Eighth  year    800  c.  c.  1.008  "    1.016  18.0 

Ninth   year     900  c.  c.  1.010  ' '    1.020  19.0 

Tenth  year     1000  c.  c.  1.012  ' '    1.020  20.0 

Frequency  of  XTrination. — Physiological  incontinence  is  the  normal 
condition  in  infancy.  At  this  time  of  life  urination  is  purely  a  reflex  act. 
In  the  new-born  it  may  not  occur  on  the  first  or  even  on  the  second  day, 
but  beginning  with  the  second  day  the  infant  usually  passes  urine  two  or 
three  times  in  twenty-four  hours,  and  thereafter,  day  by  day,  this  increases 
in  frequency  until  within  a  few  weeks  it  may  be  passing  urine  at  hour 
or  even  half-hour  intervals.  After  the  third  month  these  intervals  are 
gradually  prolonged,  so  that  by  the  end  of  the  second  year  the  bladder  of  the 
normal  infant  may  retain  urine  for  from  two  to  four  hours,  and  during 
sleep  even  longer.  A  fair  degree  of  physiological  control  of  this  function 
is  obtained  about  the  third  year.  By  this  time  the  child  should  be  able  to 
go  through  the  night  without  passing  urine,  and  should  be  able  to  control 
this  function  from  four  to  six  hours  during  the  day.  Either  nocturnal 
or  diurnal  incontinence  of  urine  after  the  third  year  is  to  be  lookedi 
upon  as  a  pathological  condition. 

LITHURIA 

This  condition  refers  to  an  excess  of  the  uric  acid  bodies  in  the  urine, 
and  implies  an  excess  of  these  same  bodies  in  the  blood  and  tissues.  As 
noted  in  the  above  table,  the  urine  of  early  infancy  has  a  relatively  low 
specific  gravity,  and  contains  a  comparatively  small  quantity  of  urea.  On 
the  other  hand,  uric  acid  is  comparatively  very  abundant,  especially  during 
the  early  days  of  life.  It  is  probable  that  in  the  fetus,  as  in  cold-blooded 
animals,  uric  acid  may  be  one  of  the  end-products  of  protein  metabolism, 
but  after  birth  this  tendency  to  uric-acid  formation  rapidly  diminishes. 
This  may  account  for  the  uric-acid  infarcts  as  well  as  the  temporary 
anuria  followed  by  the  passage  of  a  urine  rich  in  urates,  which  may  occur 
in  the  newly-born  infant  and  may  even  reach  a  degree  of  pathological  im- 
portance. These  uric-acid  infarcts,  as  Jacobi  has  taught,  may  be  a  source 
of  great  irritation,  not  only  to  the  kidneys,  but  to  the  other  urinary  organs 
as  well.  The  irritation  they  produce  in  the  kidney  may  be  manifested 
by  the  presence  of  albumin  and  casts  in  the  urine,  and  by  slight  hem- 
orrhages which  give  a  tinge  of  redness  to  the  first  urine  passed  by  the 
infant.  An  excess  of  uric  acid  in  the  infant  may  cause  a  reddish  staining 
of  the  diapers,  and  in  older  children  a  brick  dust  precipitation  may  occur 
when  it  is  allowed  to  stand.  The  ureters,  bladder,  and  urethra  may  be 
irritated  by  the  uric  acid  in  passing,  and,  as  a  result,  the  urine  may  contain 
large  numbers  of  epithelial  cells,  leukocytes,  red  blood  corpuscles,  and 


562  THE    URINE 

mucus.  Infrequently  small  renal  calculi  may  form,  and,  in  their  passage 
through  the  ureters,  may  cause  renal  colic,  or  they  may  produce  great 
distress  by  becoming  impacted  in  the  urethra.  There  may  be  a  tendency 
throughout  childhood  to  recurring  attacks  of  acid  urine  in  which  the 
urates  are  in  great  excess;  these  attacks,  as  a  rule,  occur  in  thin,  nervous, 
irritable,  quick-witted  children.  During  the  attack  the  general  nervous 
irritability  of  the  child  is  greatly  exaggerated,  the  urine  is  retained  as 
long  as  possible,  and  then  passed  with  a  fit  of  crying.  The  urine  in  some 
of  these  cases  is  so  irritating  that  the  external  genitalia  become  swollen 
and  red,  and  in  female  children  a  mild  vulvovaginitis  may  result.  These 
attacks  last  for  a  number  of  days  and  then  pass  off,  the  urine  again  re- 
turning to  normal. 

INDICANURIA 

Urinary  indican  is  almost,  if  not  quite,  entirely  derived  from  the 
bacterial  fermentation  of  the  proteins  of  the  food.  Some  observers  believe 
that  a  small  percentage  of  it  may  result  from  the  disintegration  of  albumin 
in  the  tissues.  However  this  may  be,  medical  observers  are  for  the  most 
part  agreed  that  this  latter  source  is  so  unimportant  that  it  may  be  con- 
sidered negligible  from  a  pathological  standpoint.  Indican  in  the  urine 
is  therefore  a  sign  of  bacterial  disintegration  of  proteins  in  the  intestinal 
canal,  and  the  extent  of  this  form  of  fermentation  may,  in  most  instances, 
be  largely  determined  by  the  quantity  of  indican  in  the  urine. 

Herter  has  called  attention  to  the  fact  that  indolaceturia  (indolacetic 
acid  in  the  urine)  is  also  produced  by  the  bacterial  fermentation  of  proteins 
in  the  intestinal  canal,  and  that  there  is  a  "reciprocal  relation  between 
the  formation  of  indolacetic  acid  and  indol,"  that  is  to  say,  when  the  one 
is  present  in  large  quantities  the  other  will  be  found  in  smaller  quantities. 
From  this  it  would  appear  that  both  urinary  indican  and  indolacetic  acid 
are  evidences  of  bacterial  fermentation  of  proteins  in  the  intestinal  canal. 

Indican  is  usually  absent  in  the  urine  of  normal  breast-fed  infants,  but 
is  found,  as  a  rule,  in  small  quantities  in  the  urine  of  all  other  individuals. 
It  has  pathological  significance  only  when  it  occurs  in  excess.  The  quan- 
tity is  generally  increased  in  well-marked  constipation  and  in  all  gastro- 
intestinal diseases.  The  degree  of  indicanuria,  in  many  instances,  marks 
the  severity  of  the  gastrointestinal  intoxication.  Pronounced  indolace- 
turia may  also  be  an  indication  of  intestinal  toxemia.  In  the  routine  ex- 
amination of  urine,  therefore,  the  approximate  quantity  of  indolacetic  acid 
as  well  as  indican  should  be  determined;  an  excess  of  these  bodies  in  the 
urine  is  very  commonly  associated  with  albumin,  occasional  hyalin  casts, 
and  an  excess  of  oxalate  of  lime  crystals. 

HEMATURIA 

Attention  is  usually  called  to  this  condition  by  the  color  of  the  urine, 
which  may  be  flesh-colored,  smoky,  brownish,  or  reddish;  when  the  latter, 
it  may  vary  from  the  faintest  tinges  to  a  blood-red  color,  depending  on 


HEMOGLOBINTTRIA  563 

the  quantity  of  blood  in  the  urine.  It  should  be  remembered  that  in  al- 
kaline urine  a  comparatively  small  quantity  of  blood  may  produce  a  bright 
red  color.  It  can  be  differentiated  from  hemoglobinuria  by  a  microscopical 
examination,  which  reveals  the  presence  of  red  blood  corpuscles  in  large 
numbers.  Hematuria  may  occur  under  a  great  variety  of  conditions  and 
bo  jiroduced  by  disease  or  injury  of  any  part  of  the  genitourinary  system. 
In  newly  born  infants  the  urine  passed  during  the  first  days  of  life  may 
1)6  tinged  with  blood,  as  a  result  of  irritation  from  uric-acid  crystals  and 
infarcts;  this  form  is  transitory  and  has  slight  pathological  significance. 
C*alcium  oxalate  crystals,  when  present  in  excess,  may  also  produce  hema- 
turia; this  may  sometimes  result  from  the  eating  of  rhubarb,  tomatoes, 
and  asparagus;  this  form  is  rare  and  is  largely  a  matter  of  idiosyncrasy; 
it  is  also  transitory  and  has  little  pathological  significance.  Infantile 
scurvy  is  a  cause  of  hematuria,  and  in  severe  cases  of  this  disease  red 
blood  corpuscles  may  almost  always  be  found  in  the  urine,  and  well-marked 
hemorrhages  may  occur.  Hematuria  may  be  present  as  a  symptom  of  sep- 
sis, hemophilia,  purpura  hemorrhagica,  leukemia,  severe  forms  of  variola, 
malaria,  scarlet  fever,  acute  nephritis,  calculus,  tuberculosis,  malignant 
disease,  cystitis,  neoplasms,  and  acute  inflammation  of  the  urethra  (gonor- 
rhea). It  may  also  be  produced  by  certain  drugs,  such  as  turpentine,  can- 
tharides,  and  large  doses  of  chlorate  of  potash. 

The  source  of  the  blood  in  the  urine  cannot  always  be  readily  deter- 
mined. An  examination  of  the  external  genitalia  of  the  female  will  dis- 
cover whether  the  urine  was  contaminated  after  leaving  the  urethra.  If 
the  hemorrhage  comes  from  the  kidney,  epithelial  and  blood  casts,  together 
with  renal  epithelium,  can,  as  a  rule,  be  found,  and  in  these  cases  the 
quantity  of  albumin  is  out  of  proportion  to  the  quantity  of  blood.  If  the 
blood  comes  from  the  bladder  it  commonly  follows  the  urine  and  is  passed 
with  pain  and  tenesmus;  if  the  blood  precedes  the  urine  its  source  is  the 
urethral  canal.  In  all  cases  of  hematuria  the  concomitant  symptoms  are 
important  in  determining  the  source  of  the  blood. 

Treatment.— This  will  depend  upon  the  cause.  Hematuria  is  a  symp- 
tom of  some  constitutional  disorder  or  local  disease  of  the  genitourin- 
ary tract,  and  the  treatment  of  the  causative  condition  is  therefore  the 
treatment  of  the  hematuria.  The  symptom  itself  rarely  demands  special 
treatment.  Fluid  extract  of  ergot  or  ergotin  may  be  given  where  the 
hemorrhage  is  excessive,  and  absolute  rest  in  bed  should  be  insisted  upon. 
If  the  bleeding  point  can  be  reached  by  the  injection  of  adrenalin  solution 
into  the  bladder  the  hemorrhage  may  be  controlled  in  this  way. 

HEMOGLOBINURIA 

Hemoglobinuria  is  due  to  an  extensive  disintegration  of  red  blood  cells, 
which  is  followed  by  the  appearance  of  blood  pigment  in  the  urine;  this 
pigment,  however,  is  commonly  methemoglobin,  rather  than  unchanged 
hemoglobin. 


564  THE    URINE 

The  diagnosis  is  made  by  the  urine  findings.  The  color  of  the  urine 
varies  from  a  pale  red  to  a  very  dark  red,  depending  upon  the  quantity 
of  hemoglobin  it  contains.  The  amount  of  albumin  present  also  depends 
upon  the  quantity  of  hemoglobin.  Microscopic  examination  reveals  the 
blood  pigment  in  amorphous  granules,  masses,  or  casts,  and  hemoglobin 
crystals  may  be  found,  but  the  important  diagnostic  feature  is  the  almost 
complete  absence  of  red  blood  cells.  Hyalin  and  granular  casts  are  present, 
and  renal  epithelium  and  calcium  oxalate  crystals  are  usually  found.  As 
the  patient  convalesces  from  the  attack,  the  urine  gradually  loses  its  red 
color  and  the  above  microscopic  findings  disappear. 

Etiology. — Hemoglobinuria  is  usually  an  expression  of  some  severe 
toxemia.  It  may  occur  in  septic  conditions,  scarlet  fever,  malaria,  erysip- 
elas, and  severe  forms  of  jaundice.  It  may  be  produced  by  certain  poisons, 
such  as  phenol,  naphthol,  arseniuretted  hydrogen,  toluene-diamin,  and  large 
doses  of  chlorate  of  potash.  It  may  also  result  from  the  transfusion  of 
blood,  or  the  injection  of  a  foreign  serum. 

There  are,  however,  two  rather  clearly  defined  types  of  hemoglobinuria 
which  demand  special  consideration,  namely:  Epidemic  Hemoglobinuria 
of  the  New-born,  and  Paroxysmal  Hemoglobinuria. 

WINCKEL'S    DISEASE 

Winckel's  disease,  or  epidemic  hemoglobinuria  of  the  new-born,  is  a 
rare  form  of  hemoglobinuria,  probably  due  to  sepsis.  It  makes  its  ap- 
pearance during  the  first  few  days  of  life  in  apparently  healthy  infants. 
It  has  been  observed  in  epidemic  form,  particularly  in  institutions,  where 
the  bath  water  is  regarded  as  a  method  of  infection.  An  early  symptom 
is  cyanosis,  which,  together  with  jaundice  and  hemoglobinuria,  forms  a 
striking  clinical  picture.  The  disease  is  marked  by  profound  constitutional 
symptoms,  great  depression,  a  feeble,  rapid  pulse,  cold  extremities,  and  is 
sometimes  associated  with  diarrhea  and  vomiting.  Jaundice  develops 
early,  and  is  usually  intense  within  twenty-four  hours.  The  urine  find- 
ings are  the  same  as  above  described.  The  disease  runs  a  rapid  and 
fatal  course,  commonly  terminating  within  two  or  three  days.  Convul- 
sions and  coma  may  be  the  terminal  symptoms.  The  diagnosis  of  this 
form  of  hemoglobinuria  is  made  by  the  urine  findings,  the  age  of  the 
infant,  and  the  profound  constitutional  symptoms  above  noted. 

PAROXYSMAL    HEMOGLOBINUEIA 

Paroxysmal  hemoglobinuria  is  a  chronic  intermittent  form  which  may 
come  on  in  childhood  and  recur  in  paroxysms  throughout  the  life  of  the 
individual.  In  other  instances  it  disappears  without  apparent  cause  as 
the  patient  grows  older. 

Etiology. — Syphilis  and  malaria  are  believed  to  be  important  predis- 
posing factors  in   many   cases.     Exposure  to   cold  is  the   most  common 


ACETOXUEIA  565 

exciting  cause  of  the  individual  attacks.  They  are  therefore  much  more 
usual  during  the  winter  months.  Contact  with  cold  water  is  a  very 
common  exciting  cause.  The  individual  attacks  may  begin  with  a  chill, 
which  may  be  followed  by  a  rise  of  temperature.  Cyanosis,  general  de- 
pression, nausea,  and  abdominal  pain  may  be  present,  and  the  skin  may 
be  slightly  jaundiced.  The  urine  findings  are  the  same  as  those  above 
noted.  The  attack  is  of  short  duration;  it  passes  off  within  a  few  hours 
and  the  urine  rapidly  becomes  normal.  The  frequency  of  these  attacks 
varies  greatly;  in  the  winter  they  may  recur  at  short  intervals;  during 
the  summer  they  may  be  separated  by  months. 

Prognosis.— The  prognosis,  as  far  as  life  is  concerned,  is  good.  This 
disease  may  not  shorten  life,  and  some  cases  recover  after  reaching  adult 
life. 

Treatment.— When  due  to  sepsis,  or  the  various  acute  infectious  dis- 
eases, these  causative  conditions  are  to  be  treated  rather  than  the  hemo- 
globinuria. In  the  periodic  form  antisyphilitic  and  antimalarial  treat- 
ment should  be  tried,  and  if  benefit  follows  they  should  be  continued.  Pa- 
tients suffering  from  this  disease  should  also  live  in  a  mild  and  equable 
climate,  so  as  to  avoid  sudden  chilling  of  the  surface  of  the  body.  Cold 
baths  and  other  exciting  causes,  which  in  the  individual  case  are  known  to 
precipitate  the  attack,  should  be  avoided.  Martin  H.  Fischer  believes  that 
we  can  relieve  the  signs  and  symptoms  of  paroxysmal  hemoglobinuria  by 
increasing  the  salts  in  the  diet.  Sodium  chlorid  should  be  given  in  some 
form  in  every  case  of  hemoglobinuria, 

ACETONURIA 

Oxybutyric  acid  is  the  antecedent  body  from  which  diacetic  acid  and 
acetone  are  formed.  These  three  substances  constitute  the  acetone  group, 
and  their  appearance  in  the  urine  is  indicative  of  a  definite  form  of 
acid  intoxication,  which  is  associated  with  a  large  number  of  diseased 
conditions.  Oxybutyric  acid  is  formed  by  the  disintegration  of  fat  and 
protein  molecules  under  unfavorable  conditions  of  oxidation.  Von  Noorden 
believes  that  carbohydrate  molecules  furnish  some  oxygen  to  the  fat  and 
protein  molecules,  as  they  are  disintegrated  in  the  normal  processes  of 
body  metabolism,  and  that  the  absence  of  carbohydrate  molecules  results 
in  the  imperfect  oxidation  of  the  disintegrating  fat  and  protein  molecules, 
and  thereby  causes  the  formation  of  oxybutyric  acid.  According  to  this 
view,  the  presence  of  oxybutyric  acid  in  the  blood  is  always  due  either 
to  a  deficient  intake  of  carbohydrate  foods  or  to  some  perversion  in  the 
carbohydrate  metabolism,  which  makes  it  impossible  for  them  to  exercise 
their  oxidizing  influence  on  the  disintegrating  fat  and  protein  molecules. 
It  is  my  belief  that  this  form  of  acid  intoxication  is  due  either  to  a  de- 
ficient absorption  of  carbohydrate  food  or  to  functional  or  organic  diseases 
of  the  liver,  which  interfere  with  its  glycogenic  function.  While  oxybutyric 
acid  is  the  most  important  of  the  acetone  series,  it  caimot  be  demonstrated 


566  THE    UEINE 

in  the  urine  by  simple  clinical  tests,  so  that  for  clinical  purposes  the  urine 
is  examined  for  either  diacetic  acid  or  acetone,  and  the  presence  of  either 
of  these  bodies  is  an  indication  that  this  form  of  acid  intoxication  exists. 
Oxybutyric  acid  is  the  antecedent  body;  this  is  oxidized  into  diacetic  acid 
and  then  into  acetone,  so  that  for  clinical  purposes  the  demonstration  of 
one  of  the  series  is  all  that  is  necessary.  The  oxidizing  processes  here 
referred  to  are  so  rapid  that  acetone  is  the  first  of  these  bodies  to  appear 
in  the  urine,  and  the  subsequent  appearance  of  diacetic  acid,  and  later  of 
oxybutyric  acid,  indicates  failing  powers  of  oxidation  and  therefore  a 
more  severe  form  of  autointoxication. 

This  form  of  acid  intoxication  may  produce  deleterious  results :  First, 
by  the  direct  toxic  action  of  the  acids  formed;  second,  by  removing  al- 
kaline bases,  such  as  calcium,  potassium,  sodium,  and  magnesium,  which 
are  necessary  to  the  normal  processes  of  metabolism ;  third,  by  bringing 
poisonous  alkaline  bases,  such  as  ammonium,  in  large  quantities  into  the 
blood  (Eachford)  ;  fourth,  by  separating  CO2  from  its  bases,  and  thus 
producing   carbonic   acid  poisoning    (Herter). 

The  acetone  group  may  appear  in  the  urine  in  many  pathological 
conditions,  and  it  is  found  much  more  frequently  in  children  than  in 
adults.  These  bodies  are  commonly  observed  in  diabetes,  malignant  disease, 
prolonged  fevers,  starvation,  gastrointestinal  disorders,  recurrent  vomiting, 
other  forms  of  severe  and  prolonged  vomiting,  nervous  disorders,  migraine, 
bronchopneumonia,  influenza,  severe  malnutrition,  and  in  poisoning  from 
atropin,   lead,   morphin,   antipyrin,   and  chloroform. 

Diagnosis.- — The  diagnosis  of  this  form  of  acid  intoxication  is  made  by 
the  finding  of  one  or  more  of  the  acetone  bodies  in  the  urine.  In  this 
examination  it  is  important  to  remember  that  the  reaction  with  a  solution 
of  ferrous  chlorid,  which  is  commonly  used  to  demonstrate  the  presence 
of  diacetic  acid,  may  be  unreliable  if  the  patient  has  been  taking  a  salicylate, 
since  this  drug,  when  excreted  by  the  urine,  gives  a  reaction  similar  to 
that  of  diacetic  acid.  If  the  acetone  group  is  found  in  large  quantities  in 
the  urine  it  is  an  indication  of  profound  metabolic  disturbances,  one  of 
the  results  of  which  is  the  presence  of  these  bodies  in  large  quantities  in 
the  blood.  This  form  of  acid  intoxication,  however,  is  not  characterized 
by  any  well-defined  clinical  picture.  By  some  writers  it  is  believed  that 
dyspnea,  increased  pulse  rate,  somnolence,  and  coma,  which  occur  in  many 
of  these  cases,  are  either  directly  or  indirectly  due  to  the  acetone  bodies.  In 
all  of  these  cases  there  is  an  increase  in  the  urinary  ammonia,  and  in 
some  instances  a  decrease  in  the  alkalescence  of  the  blood. 

Prognosis. — The  prognosis  depends  upon  the  cause.  If  acetonuria 
appears  as  a  symptom  of  advanced  diabetes  or  cancer,  the  prognosis  is 
unfavorable,  but  even  in  these  cases  one  may  temporarily  cause  to  dis- 
appear the  coma  and  other  symptoms  associated  with  the  acidosis.  In 
the  acetonuria,  which  occurs  in  acute  malnutrition,  intestinal  disorders, 
fevers,  and  "recurrent"  and  other  forms  of  severe  vomiting,  the  prognosis 
is  nearly  always  good.     There  is  a  form  of  acidosis  occurring  in  children 


ALBUMINURIA  567 

under  three  years  of  age  associated  with  intestinal  disturbance  and  dyspnea 
which  may  terminate  fatally. 

Treatment. — For  the  immediate  relief  of  an  attack  of  acidosis,  from 
3  to  5  grains  of  calomel,  combined  with  bicarbonate  of  soda,  should  be 
given,  and  should  be  followed  by  a  saline  laxative.  Immediately  afterward 
the  administration  of  alkalies  in  large  doses  should  be  begun.  The  al- 
kaline treatment,  which  consists  in  the  giving  of  bicarbonate,  or  benzoate 
of  soda,  should  be  continued  for  some  time,  in  smaller  doses,  after  the 
acetone  bodies  have  disappeared  from  the  urine.  During  convalescence, 
and  for  the  prevention  of  these  attacks,  fresh  air,  preferably  out-of-door 
air,  is  indicated,  and  this  should  be  continued  throughout  the  twenty-four 
hours,  the  patient  either  sleeping  out  of  doors  or  with  wide  open  windows. 
Carbohydrate  foods  are  especially  indicated,  and  should  always  be  given 
when  the  condition  of  the  patient  will  permit.  Exercise  out  of  doors  is 
to  be  recommended  in  all  cases  where  the  individual  is  strong  enough  to 
be  benefited  by  it.  Where  the  physical  condition  of  the  patient  is  such 
that  outdoor  exercise  cannot  be  indulged  in,  general  massage  is  to  be 
recommended.  A  more  detailed  account  of  the  treatment  of  acidosis  is 
given  in  the  chapter  on  Recurrent  Vomiting. 

ALBUMINURIA 

The  presence  of  albumin  in  the  urine  is  not  always  an  indication  of 
structural  disease  of  the  kidney.  On  the  other  hand,  it  is  now  a  well- 
recognized  fact  that  transient  forms  of  albuminuria  may  occur,  even 
associated  with  an  occasional  hyalin  or  epithelial  cast  in  conditions  other 
than  true  nephritis.  It  is  necessary,  therefore,  that  these  forms  of 
albuminuria  should  be  carefully  studied  in  order  that  they  may  not  be 
confused  with  nephritis,  and  it  is  even  more  important  that  cases  of  true 
nephritis  should  not  be  mistaken  for  these  more  innocent  forms  of  al- 
buminuria. The  following  forms  of  albuminuria  may  be  recognized :  Phy- 
siological,  orthostatic,  toxic,  and  nephritic. 

PHYSIOLOGICAL   ALBUMINURIA 

This  is  the  transient,  or  intermittent,  appearance  of  albumin  in  such 
quantities  that  it  may  be  easily  discovered  by  ordinary  tests  in  the 
otherwise  normal  urine  of  a  healthy  child.  It  is  comparatively  unim- 
portant and  deserves  but  passing  notice.  It  may  result  from  the  following 
causes:  excessive  muscular  exercise,  such  as  bicycling,  foot-racing,  and 
jumping  the  rope;  emotional  excitement,  such  as  may  result  from  mas- 
turbation, or  pseudomasturbation — this  form  has  little  or  no  pathological 
significance;  sudden  and  prolonged  chilling  of  the  surface  of  the  body, 
such  as  may  come  from  a  cold  bath,  the  albumin  from  this  cause  readily 
disappears  as  the  child  reacts,  and  may  be  due  either  to  nervous  shock  or 
temporary  congestion  of  the  kidney;  overfeeding  with  albuminous  food, 
this  cause  is  sometimes  associated  with  injuries  to  the  metabolism  from 


568  THE    URINE 

the  inability  of  the  excretory  organs  to  eliminate  the  excess  of  foreign 
albumin  in  the  circulating  media  of  the  body.  In  each  of  the  above 
instances  the  question  may  arise  as  to  whether  the  term  physiological  can 
properly  be  used  to  designate  these  albuminurias,  but  certain  it  is  that 
they  may  occur  entirely  apart  from  disease  of  the  kidneys,  and  that  their 
pathological  importance  is  so  slight  that  they  can  scarcely  be  classified 
under  any  other  heading.  The  transient  appearance  of  a  faint  trace  of 
albumin  or  an  occasional  hyalin  cast  may  have  no  pathological  significance ; 
in  fact  these  findings  are  very  common  in  the  urine  of  normal  children. 

The  albuminuria  of  the  new-born  has  been  designated  as  physiological. 
Much  attention  has  been  given  to  this  form  by  German  writers,  all  of 
whom  are  agreed  that  it  occurs  in  a  large  percentage  of  infants  during 
the  first  week  of  life,  and  in  a  few  may  persist  until  the  end  of  the 
second  or  third  week  without  being  considered  a  pathological  process.  It 
is  most  frequently  found  during  the  first  and  second  days  of  life,  but  the 
percentage  of  infants  having  albuminuria  rapidly  diminishes  after  the 
third  day,  so  that  if  it  persists  to  the  end  of  the  second  week  it  is  perhaps 
wise  to  consider  it  a  pathological  process,  unless  it  can  be  shown  to  belong  to 
one  of  the  other  forms  of  physiological  albuminuria  above  mentioned.  In 
some  instances  the  albuminuria  of  the  new-born  may  be  due  to  incomplete 
functional  development  of  the  kidney,  which  results  in  a  defect  in  its 
filtering  function;  or  in  others  it  may  result  from  the  irritation  of  uric 
acid  crystals  and  infarcts,  which  irritate  the  tubules  of  the  kidney  to  such 
an  extent  that  not  only  albumin  appears  but  occasional  hyalin  and  epithelial 
casts  are  present;  or,  again,  it  may  be  toxic,  due  to  the  irritation  of  the 
very  vulnerable  kidney  of  the  newly  born  infant  by  intestinal  and  other 
toxins.  Whatever  may  be  the  cause  of  these  forms  of  albuminuria  in 
the  new-born,  they  are  of  no  pathological  importance,  since  the  urine 
quickly  clears  and  leaves  the  kidney  in  a  normal  condition.  For  this 
reason  they  can  scarcely  be  classified  as  pathological. 

ORTHOSTATIC    ALBUMINURIA 

This  form  was  first  described  by  Pavy,  under  the  name  of  Cyclic  Al- 
buminuria. Since  his  observations,  the  condition  has  been  very  extensively 
studied  by  many  observers,  and  Heubner  proposed  for  it  the  name  Or- 
thotic, or  Orthostatic,  Albuminuria,  which  term  expresses  the  important 
fact  in  its  etiology,  that  the  albuminuria  is  postural,  coming  on  when 
the  patient  is  on  his  feet  and  disappearing  when  he  assumes  the  re- 
cumbent posture.  Pavy  used  the  term  cyclic  to  express  practically  the 
same  condition;  he  found  no  albumin  in  the  earlj^-morning  urine,  while 
that  passed  during  the  day  always  contained  albumin.  This  cycle  which 
Pavy  described,  was  later  found  to  be  due  not  to  the  particular  time  of 
day  when  the  urine  was  secreted,  but  to  the  upright  position  of  the  patient 
during  the  day  and  the  prone  position  during  the  night.  jSTo  albuminous 
cycle  occurs  in  these  cases  as  long  as  the  patient  is  confined  to  bed; 
under  this  condition  both  the  night  and  day  urines  are  free  from  albumin. 


ALBUMINUEIA  569 

Etiology. — This  is  a  pathological,  not  a  functional  or  physiological, 
form  of  albuminuria.  It  is  not,  however,  a  symptom  of  nephritis,  and, 
in  the  great  majority  of  instances,  does  not  lead  to  actual  disease  of  the 
kidney.  The  fact  should  be  kept  in  mind  that  all  forms  of  pathological 
albuminurias,  including  the  toxic  and  nephritic  varieties,  are  aggravated 
by  the  ujjright  position,  and  these  forms  must  therefore  be  carefully  dif- 
ferentiated from  true  orthostatic  albuminuria. 

Heredity  plays  an  important  role  in  the  etiology  of  this  condition.  A 
family  predisposition  is  not  infrequently  found.  The  exact  character  of 
this  heredity  is  unknown,  but  a  gouty  and  neurotic  inheritance  is  very 
commonly  present.  The  hereditary  defect,  how^ever,  is  perhaps  a  certain 
degree  of  functional  disability  on  the  part  of  the  renal  epithelium,  which 
permits  the  albumin  of  the  blood  to  filter  through  under  slightly  abnormal 
conditions.  The  fact  that  the  upright  position  is  the  all-important  factor 
in  producing  this  form  has  led  to  the  belief  that  some  circulatory  dis- 
turbance of  the  kidney,  which  is  aggravated  by  this  position,  is  the  de- 
termining factor.  Some  observers  have  been  able  to  demonstrate  dis- 
placement of  the  kidney  in  a  considerable  percentage  of  these  cases;  in 
the  great  majority  of  instances,  however,  the  kidney  is  in  normal  position. 
As  this  disease  appears  most  frequently  between  the  ages  of  six  and  four- 
teen, during  the  rapid  growth  of  the  child,  it  has  been  suggested  that 
the  instability  of  the  abdominal  viscera  during  this  period  is  one  of 
the  causes  of  the  disturbed  circulation  in  the  kidney.  Jehle  believes  that 
lordosis  of  the  lumbar  vertebrae  is  an  important  etiological  factor  in 
many  of  these  cases.  This  disease,  or  rather  the  pathological  condition 
with  which  postural  albuminuria  is  associated,  is  aggravated  by  anything 
that  lowers  the  vitality  of  the  child.  Neurotic  disturbances,  functional 
incompetency  of  the  liver,  acute  illness,  and,  in  short,  all  the  conditions 
which  are  responsible  for  physiological  and  toxic  albuminuria  will  aggra- 
vate orthostatic  albuminuria. 

Symptomatology. — While,  in  a  few  instancees,  there  is  nothing  to  mark 
this  condition  except  the  urine  findings,  in  the  great  majority  of  cases  there 
are  more  or  less  well-marked  constitutional  symptoms.  My  experience  is 
in  accord  with  that  of  Longstein,  Heubner,  Still,  and  others,  that  pa- 
tients suffering  from  orthostatic  albuminuria  are  physically  below  par; 
they  are  commonly  nervous,  anemic,  have  dark  circles  under  their  eyes, 
are  easily  exhausted,  and  suffer  frequently  from  headaches  and  abdominal 
pain.  I  have  observed  that  many  of  them  have  feeble  digestive  capacity, 
and  suffer  from  fermentative  disturbances  in  the  intestinal  canal;  indican 
and  oxalic  acid  are  frequently  found  in  excess  in  the  urine,  and  not  in- 
frequently the  albuminuria  is  increased  or  diminished  in  proportion  to  the 
amount  of  these  ingredients. 

Urine  Findings. — The  diagnosis  can  be  made  only  by  repeated  careful 
examinations  of  urine,  passed  under  various  conditions  of  diet  and  posture. 
The  urine  secreted  while  the  patient  is  lying  down  is  normal,  containing 
neither  albumin  nor  casts,  but  the  urine  passed  after  the  patient  has  as- 


570  THE    UKINE 

sumed  the  upright  position  contains  albumin,  sometimes  in  large  quan- 
tities. In  a  patient  whom  I  have  had  under  observation  since  1903  and  who 
has  now  entirely  recovered,  albumin  was  often  present  in  the  early  months 
of  the  treatment  in  quantities  of  I/2  P^r  cent.,  and  could  at  all  times,  when 
she  was  in  an  upright  position,  be  easily  demonstrated  by  the  ordinary 
clinical  tests.  Besides  the  albumin  in  these  cases,  one  not  infrequently 
finds  an  occasional  hyalin  cast,  and  in  rare  instances  an  occasional 
epithelial  or  leukocyte  cast ;  cylindroids  are  also  occasionally  present ;  leuko- 
cytes, squamous  epithelium,  and  crystals  of  calcium  oxalate,  and  uric  acid 
are  not  uncommon.  I  have  carefully  studied  the  influence  of  exercise  on 
these  patients  and  have  found  that  it  does  not  increase  the  albuminuria. 
They  will  have  more  albumin  in  their  urine  when  they  are  confined  to  the 
house,  sitting  and  walking  about,  engaged  in  ordinary  indoor  occupations, 
than  they  will  if  made  to  take  exercise  in  the  open  air.  Walking,  horse- 
back riding,  golf,  and  other  outdoor  exercises  diminish  rather  than  in- 
crease the  albuminuria.  A  milk  diet  will  not  diminish  the  albuminuria; 
on  the  other  hand,  it  will,  if  prolonged,  aggravate  it.  These  are  im- 
portant points  in  the  differential  diagnosis  of  this  condition  from 
nephritis. 

Prognosis. — The  present  status  of  our  knowledge  of  orthostatic  al- 
buminuria makes  it  advisable  that  the  physician  render  a  guarded  prog- 
nosis. There  is  no  question  but  that  some  of  the  cases,  which  have  been 
carefully  studied  by  competent  observers,  have  ultimately  terminated  in 
nephritis.  On  the  other  hand,  there  can  be  no  question  but  that  many 
of  these  cases,  after  years  of  albuminuria,  permanently  recover.  On  the 
whole,  it  may  be  said  that  the  prognosis  is  favorable,  and  that,  under 
proper  care,  most  of  these  cases  get  well. 

Treatment. — These  patients  should  lead  an  outdoor  life  in  fresh  air, 
and  take  a  moderate  amount  of  physical  exercise.  In  beginning  the 
treatment,  it  is  important  that  the  amount  of  exercise  prescribed  should 
fit  the  individual  case,  otherwise  the  child  may  be  overfatigued,  but  as 
health  and  strength  return  no  limitation  should  be  placed  upon  the  outdoor 
exercise  other  than  that  overfatigue  should  be  avoided.  They  are  never 
benefited  by  rest  in  bed;  this  is  a  measure  which  is  only  justifiable  for 
the  purpose  of  making  the  diagnosis.  An  exclusive  milk  diet  is  not  only 
inadvisable,  but,  if  prolonged,  does  harm.  A  liberal  diet  of  milk,  cereals, 
vegetables,  fruits,  and  a  moderate  amount  of  meat  and  eggs  should  be 
prescribed.  I  have  not  been  able  to  satisfy  myself  that  a  moderate  amount 
of  albuminous  foods,  such  as  meat  and  eggs,  exerts  any  unfavorable  in- 
fluence. The  restriction  therefore  along  this  line  should  be  that  these 
albuminous  foods  are  not  taken  in  excess.  I  have  further  convinced  my- 
self that  these  cases  are  benefited  by  the  rigid  exclusion  of  sweets  from 
the  diet.  Wines  and  malt  liquors  are  also  contraindicated ;  rich  and  highly 
seasoned  foods  are  not  to  be  recommended.  In  two  instances  I  have  beer 
convinced  that  rhubarb  aggravated  the  albuminuria.  Still  advises  that 
this  vegetable,  together  with  tomatoes  and  asparagus,  be  excluded  from 


ACUTE  NEPHRITIS  571 

the  diet.  I  further  advise  the  drinking  of  water  between  meals,  and,  above 
all,  that  the  food  of  the  patient  should  be  selected  to  suit  his  individual 
digestive  capacity.  Intestinal  fermentation  is  to  be  carefully  avoided,  and 
the  patient's  whole  life  is  to  be  so  directed  that  his  general  health  may 
be  improved  and  his  power  of  resistance  increased.  The  albuminuria 
cannot  be  influenced  by  the  medical  or  other  therapeutic  measures  which 
favorably  influence  the  albuminuria  of  Blight's  disease. 


CHAPTER  LXXIV 
ACUTE    NEPHEITIS 

From  a  pathological  standpoint  the  term  acute  nephritis  comprehends  a 
variety  of  degenerative  and  inflammatory  changes  which  are  produced  in  the 
kidney  by  the  action  of  the  toxins  and  microorganisms.  The  degenerative 
changes,  which  are  confined  chiefly  to  the  epithelial  cells,  are  for  the 
most  part  caused  by  the  action  of  toxins.  The  inflammatory  changes, 
which  include  not  only  degeneration  of  epithelial  structures  but  the  in- 
filtration of  the  kidneys  by  newly  formed  cells,  and  perhaps  later  by 
increased  growth  of  connective  tissue,  are  produced  by  the  combined  ac- 
tion of  bacteria  and  their  toxins.  Martin  H.  Fischer  believes  that  an 
abnormal  production  or  accumulation  of  acid  in  the  kidneys,  acting  on  their 
colloidal  structures,  explains  the  pathological  findings  and  the  resulting 
symptoms  of  nephritis.  In  the  present  state  of  our  knowledge,  however, 
we  are  not  prepared  to  clearly  differentiate  either  from  a  clinical  or  path- 
ological standpoint  between  a  purely  degenerative  (toxic)  and  an  inflam- 
matory (mycotic)  nephritis.  It  is  a  recognized  fact  that,  in  some  instances, 
both  the  so-called  degenerative  and  inflammatory  lesions  may  be  pro- 
duced in  the  kidney  by  the  action  of  bacterial  and  other  toxins  without 
the  kidney  itself  being  infected  with  bacteria.  On  the  other  hand,  it  is 
generally  believed  that  in  a  large  percentage  of  the  so-called  true  inflam- 
matory processes  of  the  kidney,  and  especially  in  those  of  a  severe  type, 
the  kidney  itself  is  infected  with  pathogenic  microorganisms.  While  we 
recognize  the  existence  therefore  of  a  toxic  and  of  a  mycotic  form  of 
nephritis,  we  cannot,  from  a  clinical  standpoint,  clearly  differentiate  these 
conditions.  We  know,  however,  that  in  the  vast  majority  of  instances 
the  disease  begins,  and  in  a  large  percentage  of  cases  remains  a  purely 
degenerative  process  produced  by  the  irritating  action  on  the  kidney  of 
toxins.  We  know  also  that  in  a  considerable  number  of  these  cases  the 
degenerative  changes  thus  produced  predispose  this  organ  to  infection, 
and  that  a  mycotic  nephritis  is  added  to  the  toxic  nephritis,  and  when 
this  occurs  the  gravity  of  the  disease  is  greatly  increased.  We  know  also 
that  a  small  percentage  of  the  eases  of  nephritis  may  be  classed  as  pri- 
marily mycotic,  that  is  to  say,  the  kidney  is  attacked  by  pathogenic  micro- 
organisms before  degenerative  changes  in  the  epithelial  structures  have 


572  ACUTE  NEPHRITIS 

prepared  the  way  for  this  infection.  These  cases  are  usually  of  a  very 
severe  type,  and  occur  either  as  so-called  idiopathic  or  primary  cases,  or 
during  the  first  week  of  one  of  the  acute  infections,  such  as  scarlet  fever, 
diphtheria,  and  influenza.  The  terms  parenchymatous,  tubular,  and  glomer- 
ular nephritis  have  been  used  to  describe  various  localizations  of  the 
ordinary  toxic,  or  degenerative,  form,  while  the  terms  acute  diffused 
nephritis  and  acute  productive  nephritis  have  been  used  to  describe  the 
more  severe  inflammatory  types.  From  a  clinical  standpoint,  however, 
this  classification  is  of  no  assistance.  For  these  reasons  we  shall  speak 
of  the  toxic  and  mycotic  forms  of  acute  nephritis,  recognizing  that  they  are 
frequently  commingled,  and,  even  when  distinct,  may  be  difficult  of  differ- 
entiation. 

TOXIC    NEPHRITIS 

{Toxic  Albuminuria) 

The  severity  of  this  form  depends  upon  the  virulence  of  the  toxin,  the 
length  of  time  it  acts  on  the  kidney,  and  the  part  of  the  secreting  structure 
attacked.  These  cases  may,  by  bacterial  infection,  be  converted  into  a  true 
mycotic  nephritis,  but  in  the  great  majority  of  instances  they  run  a  benign 
course,  the  albumin  and  casts  disappearing  as  the  patient  recovers  from 
the  disease,  systemic  or  intestinal,  which  is  producing  the  toxemia. 

Etiology. — This  form  of  nephritis  is  commonly  produced  by  scarlet 
fever,  pneumonia,  infiuenza,  septicemia,  malaria,  rheumatism,  cerebrospinal 
meningitis,  and  gastrointestinal  infections.  Chapin,  Morse,  and  others  have 
called  special  attention  to  the  frequency  of  albuminuria  in  pneumonia  and 
cerebrospinal  meningitis.  Chapin  reported  "a  series  of  57  cases  of  pul- 
monary diseases,  such  as  severe  bronchitis,  pleurisy,  and  pneumonia,  that 
gave  the  following  results:  49  had  albumin  in  the  urine,  thus  noted; 
trace,  13 ;  faint  trace,  30 ;  heavy  trace,  6 ;  32  cases  had  casts  present,  either 
hyalin,  granular,  epithelial,  or  mucous.''  In  infanc}^,  disease  of  the  gastro- 
intestinal tract,  as  Kjelberg  demonstrated,  is  the  m.ost  common  cause  of 
this  condition;  Koplik,  Morse,  Chapin,  and  many  others  have  also  noted 
this  fact.  In  Koplik's  series  of  25  cases  of  gastroenteritis  all  but  4 
had  albuminuria,  and  in  more  than  one-half  casts  were  found.  In  Chapin's 
86  cases  of  gastrointestinal  disease,  albumin  was  present  in  75,  and  casts, 
hyalin,  granular,  epithelial,  or  mucous,  were  present  in  37.  It  is  a 
notable  fact  that  in  cases  of  gastrointestinal  origin  the  albumin  in  the 
urine  rises  and  falls  with  the  amount  of  indican.  This,  however,  does 
not  necessarily  mean  that  the  indican  produces  the  irritation  of  the  kidney, 
but  it  does  indicate  that  the  products  of  the  intestinal  fermentation  of 
albuminous  foodstuffs,  of  which  indican  is  one,  are  largely  responsible 
for  this  irritation. 

Severe  anemia,  scurvy,  icterus,  and  diabetes  may  be  associated  with 
albuminuria,  the  cause  of  which  is  perhaps  toxic.  Migi-aine,  "recurrent 
vomiting,"   and   other   autointoxications   may   produce    albuminuria;  the 


TOXIC    NEPHRITIS  573 

writer,  many  years  ago,  called  attention  to  the  presence  of  transient  al- 
buminurias occurring  in  connection  with  these  toxic  states. 

A  few  drugs  and  chemicals,  such  as  turpentine,  chlorate  of  potash, 
carbolic  acid,  cantharides,  arsenic,  and  phosphorus,  may,  when  taken  in 
excess,  produce  a  toxic  nephritis.  In  some  of  these  cases  the  irritation 
to  the  kidney  may  be  so  great  as  to  produce  a  violent  inflammation  as- 
sociated with  severe  and  dangerous  constitutional  symptoms. 

Symptomatology.— In  the  great  majority  of  these  cases  the  diagnosis 
must  be  made  almost  exclusively  by  the  urine  findings,  since  no  con- 
stitutional symptoms  referable  to  the  kidney  lesions  are  present.  This  is 
especially  true  in  the  toxic  albuminurias  which  occur  in  infants  and  young 
children  suffering  from  catarrhal  diseases  of  the  intestinal  canal  and 
respiratory  tract,  as  well  as  in  older  children  suffering  from  some  form 
of  autointoxication,  or  one  of  the  acute  infections.  In  these  cases  the  con- 
stitutional symptoms  of  the  original  infection  are  present,  and  the  kidney 
lesion  is,  as  a  rule,  accidentally  discovered  by  an  examination  of  the  urine. 
It  must,  however,  be  remembered  that  even  the  purely  toxic  forms  of  neph- 
ritis may  occasionally  be  associated  with  kidney  lesions  so  severe  as  to 
produce  uremic  and  other  constitutional  symptoms.  The  symptom  group 
occurring  in  these  cases  is  similar  to  that  detailed  under  the  heading 
Mycotic  Nephritis. 

The  urine  findings  upon  which  the  diagnosis  is  made  are  as  follows: 
albumin,  usually  not  a  great  amount;  a  small  number  of  hyalin  and 
epithelial  casts;  leukocytes,  epithelial  cells  and  mucus.  The  quantity  of 
the  urine  may  not  be  diminished,  but  the  specific  gravity  is  usually  high, 
sometimes  above  1,020. 

Diagnosis.-^If  the  physician  keeps  in  mind  the  fact  that  in  all  the 
above-named  conditions  mild  forms  of  toxic  (degenerative)  nephritis  are 
very  common,  and  that  severe  forms  of  acute  mycotic  nephritis  are  com- 
paratively rare,  he  will  then  not  easily  be  misled  by  the  urine  findings 
above  noted.  The  small  amount  of  albumin,  the  comparative  scarcity 
of  casts,  and  the  absence  of  all  constitutional  symptoms  referable  to  the 
kidney  would  justify  the  diagnosis  of  a  simple  toxic  nephritis. 

Prognosis. — The  great  majority  of  these  cases  recover  without  ap- 
parently influencing  the  course  of  the  disease  with  which  they  are  asso- 
ciated. Earely,  however,  the  toxins  may  be  so  virulent  or  their  action 
on  the  kidney  may  be  so  long  continued  as  to  produce  severe  and  dan- 
gerous forms  of  nephritis.  In  some  instances,  also,  the  toxic  nephritis 
may  predispose  to,  and  later  be  associated  with,  a  true  mycotic  nephritis. 

Treatment. — The  object  of  all  treatment  is  to  protect  the  kidneys,  whose 
secreting  structures  are  beginning  to  break  down  under  the  elimination 
of  excessive  quantities  of  toxins.  This  may  be  accomplished  in  three  ways, 
namely :  diminishing  the  toxemia,  eliminating  the  toxins  through  other  or- 
gans than  the  kidney,  and  protecting  the  kidney  by  a  non-irritating  diet. 
In  cases  associated  with  gastrointestinal  intoxication  much  can  be  done 
to  diminish  the  toxemia  by  laxative  medication.    So  that  in  every  instance. 


574  ACUTE  NEPHBITIS 

whatever  may  be  the  cause  of  the  toxemia,  a  cathartic  should  be  given,  and 
the  primary  disease  producing  it  should  then  receive  appropriate  treat- 
ment, especially  with  reference  to  diminishing  and  controlling,  as  quickly 
as  possible,  the  general  toxic  condition.  A  most  important  part  of  the 
treatment  consists  in  eliminating  the  toxins  through  other  channels  than 
the  kidney.  This  may  be  done  by  saline  cathartics,  by  warm  baths,  and 
by  the  administration  of  large  quantities  of  alkaline  water.  Perhaps  most 
important  of  all  is  the  dietetic  treatment.  Where  the  gastrointestinal 
canal  is  not  involved  and  the  question  of  diet  pertains  simply  to  the  pro- 
tection of  the  kidneys,  the  food  given  should  be  similar  to  that  recom- 
mended in  acute  mycotic  nephritis,  milk  and  cereals  predominating.  In 
many  of  these  cases,  especially  those  associated  with  pneumonia  and  acute 
septic  conditions,  the  advisability  of  the  administration  of  alcohol  may 
arise,  the  causative  condition  perhaps  demanding  alcoholic  stimulation, 
which  is  contraindicated  by  the  presence  of  albumin  and  casts  in  the 
urine.  The  urgency  of  the  symptoms  of  the  causative  condition  may,  in 
some  of  these  cases,  demand  that  the  dietetic  treatment  of  the  kidney  irri- 
tation should  be  temporarily  neglected. 

ACUTE    MYCOTIC    NEPHRITIS 

{Acute  Diffuse   Nephritis,   Acute   Productive   Nephritis,   Acute   Brighfs 
Disease,  True  Nephritis) 

This  is  an  acute  non-suppurative  inflammation  produced  by  bacteria 
and  their  toxins.  It  may  involve  any  part  or  all  of  the  kidney  structure. 
Etiology.- — It  commonly  occurs  as  a  complication  or  a  manifestation 
of  the  acute  infectious  diseases;  in  these  conditions  the  primary  inflam- 
mation is  usually  started  by  the  irritation  of  bacterial  toxins,  which  are 
eliminated  in  large  quantities  through  the  urine.  The  kidney  structures 
thus  inflamed  are  in  no  condition  to  resist  the  pathogenic  microorganisms, 
which  are  also  being  excreted  by  them,  and,  as  a  result,  a  mycotic  infection 
is  added  to  the  toxic  nephritis.  This  secondary  mycotic  nephritis  usually 
occurs  late  in  the  causative  disease,  ofttimes  when  the  patient  is  believed 
to  be  convalescent  from  the  acute  infection.  While  secondary  or  late  my- 
cotic nephritis  is  one  of  the  most  severe  and  dangerous  complications  of 
the  acute  infectious  diseases,  yet  it  is  nothing  like  so  dangerous  as  the 
form  of  acute  nephritis  which  is  produced  by  a  primary  mycotic  infection 
of  the  kidney.  Acute  nephritis  of  this  type  occurs  during  the  early  acute 
symptoms  of  the  causative  infection,  and  becomes  at  once  the  most  serious 
and  dominating  symptom-complex  of  the  disease;  it  not  infrequently  as- 
sumes the  acute  hemorrhagic  form.  The  so-called  idiopathic  or  primary 
cases  of  acute  nephritis,  which  occur  in  young  children,  and  whose  etiology 
is  so  obscure,  represent  a  small  percentage  of  this  class  of  cases.  The 
kidney  is  the  organ  primarily  attacked,  or  the  preliminary  symptoms  of 
the  influenza,  tonsillitis,  "cold,"  or  other  causative  factors  are  so  slight 
as  to  be  overlooked  until  a  sharp  and  severe  mycotic  nephritis  calls  at- 


ACUTE    MYCOTIC    NEPHEITIS  575 

tention  to  the  infection.  The  term,  primary  nephritis,  may  therefore,  per- 
haps, be  used  in  describing  these  cases,  but  the  term  "idiopathic"  is  mis- 
leading and  should  be  discarded. 

Scarlet  fever,  of  all  the  acute  infections,  is  most  commonly  followed  by 
acute  nephritis.  In  this  disease  the  skin  is  largely  put  out  of  function  by 
the  acute  dermatitis,  and  the  kidney  is  therefore  called  upon  to  do  an 
enormous  amount  of  work,  under  which  it  very  frequently  breaks  down, 
and  an  acute  toxic  or  mycotic  nephritis  results.  In  addition  to  this,  the 
scarlatinal  poison  has  a  selective  action  on  the  kidney,  and  especially  on 
its  glomeruli,  hence  the  term  glomerular  nephritis.  Scarlatinal  nephritis 
usually  occurs  late  in  the  disease,  and  has  a  very  gradual  or  insidious 
onset.  It  may,  however,  occur  during  the  first  week;  this  form,  which  is 
comparatively  rare,  is  sudden  in  its  onset,  violent  in  its  course,  and  not 
infrequently  assumes  the  hemorrhagic  type,  Nephritis  may  also  be  pro- 
duced by  influenza,  diphtheria,  enteritis,  variola,  rheumatism,  malaria,  ton- 
sillitis, typhoid  fever,  pneumonia,  septicemia,  measles,  varicella,  and  con- 
genital syphilis.  It  should  also  be  remembered,  as  previously  noted,  that 
certain  drugs  and  chemicals,  such  as  turpentine,  chlorate  of  potash,  car- 
bolic acid,  cantharides,  arsenic,  and  phosphorus  may,  in  rare  instances, 
produce  violent  inflammations  of  the  kidneys,  and  that  the  toxic  nephritis 
thus  set  up  may  terminate  in  a  true  mycotic  nephritis. 

The  influence  of  cold  as  a  cause  of  nephritis  has  probably  been  greatly 
exaggerated;  it  may  be  a  contributing  factor.  It  is  difficult  to  conceive 
how  exposure  to  cold  as  an  independent  factor  may  produce  nephritis,  but 
it  is  easy  to  understand  that  it  may  be  very  important  if  the  child  be  suffer- 
ing from  some  acute  infection,  that  is  to  say,  if  the  kidney  be  already 
irritated  by  the  presence  of  toxins  or  microorganisms. 

Symptomatology. — Clinical  experience  has  taught  me  to  believe  that 
one  may  determine,  by  the  character  of  the  onset  and  by  the  violence  of 
the  early  symptoms,  whether  the  disease  is  primarily  toxic  or  mycotic  in 
its  origin.  The  toxic  cases  are  more  insidious  and  commonly  present  no 
constitutional  symptoms;  if,  however,  bacterial  infection  is  added  to  toxic 
irritation  of  the  kidney,  pronounced  and  often  violent  constitutional  symp- 
toms are  gradually  added  to  the  symptom  group.  Cases  of  this  character 
occur  as  a  late  complication  of  one  of  the  acute  infectious  diseases.  The 
primary  mycotic  cases  on  the  other  hand  are  comparatively  violent  in  their 
onset,  and  occur  with  the  initial  symptoms  of  the  causative  disease.  Under 
this  heading  one  may  include  all  those  cases  of  nephritis  which  occur 
during  the  first  week  of  the  acute  infectious  diseases,  and  probably  all  the 
so-called  "idiopathic"  or  primary  cases  in  which  the  exciting  cause  is  not 
apparent.  These  so-called  primary  cases  have  been  carefully  studied  and 
described  by  Holt  and  others;  they  occur  in  young  children,  are  violent 
in  their  onset,  and  run  a  severe  and  usually  fatal  course. 

There  are  three  early  manifestations  of  acute  nephritis,  any  one  of 
which  may  suggest  its  onset :  First,  edema,  especially  of  the  face ;  second, 
certain  nervous  uremic  manifestations,  such  as  headache,  vomiting,  drow- 
88 


576  ACUTE  NEPHRITIS 

siness,  and  disturbances  of  vision;  third,  the  appearance  of  albumin  and 
casts  in  the  urine.  The  physician  should  therefore  be  ever  on  the  lookout 
for  these  signs  of  nephritis,  especially  when  he  is  treating  one  of  the  acute 
infectious  diseases  of  childhood. 

Dropsy  is  one  of  the  common  symptoms  of  nephritis,  developing  early 
in  the  disease  and  usually  first  showing  itself  as  a  slight  edema  of  the 
face.  The  eyelids  may  be  puffy,  and  the  whole  face  may  gradually  become 
slightly  edematous,  presenting  a  peculiar  pallid  color ;  later  the  same  piiffy 
edematous  condition  of  the  skin  may  appear  in  the  hands  and  over  the 
lumbar  region.  In  some  instances  the  dropsy  may  spread,  producing  a 
general  anasarca;  the  whole  body  including  the  legs,  arms,  back,  abdomen, 
and  scrotum,  may  be  swollen  and  edematous,  and  the  peritoneal  and  other 
serous  cavities  may  contain  large  quantities  of  fluid.  These  cases  of  ex- 
tensive dropsy  occur  most  commonly  in  scarlatinal  nephritis,  but  marked 
dropsy  may  also  be  associated  with  nephritis  due  to  other  causes.  The. 
extent  of  the  dropsy  is  of  comparatively  little  value  in  prognosis,  since 
not  infrequently  fatal  cases  of  nephritis  occur  with  little  or  no  evidence  of 
it,  and,  on  the  other  hand,  cases  presenting  most  extensive  dropsy  not  un- 
comnwnly  terminate  in  complete  recovery.  The  extent  of  the  dropsy  is 
not  in  proportion  to  the  severity  of  the  inflammation  of  the  kidney,  but 
is  believed  to  be  partly  due  to  injury  inflicted  by  the  toxins  upon  the  blood 
and  l\Tnph  vessels. 

Idiopathic  Edema. — Attention  should  be  directed  to  the  fact  that 
edema  may  occur  in  infants  quite  apart  from  disease  of  the  kidneys;  this 
form  is  most  frequently  associated  with  gastroenteritis.  I  have  observed 
this  condition  in  children  suffering  from  acute  enteritis  who  were  being 
fed  exclusively  upon  beef  broth,  meat  juice,  and  whiskey,  and  I  have  seen 
the  edema  quickly  disappear  when  these  foods  were  changed  for  a  mod- 
ified milk  formula.  Idiopathic  edema  is  not  in  any  way  related  to  nephritis, 
and  is  mentioned  here  simply  to  prevent  mistakes  in  diagnosis. 

Uremia. — Headache,  nausea,  and  vomiting  are  the  early  symptoms 
which  mark  the  onset  of  this  intoxication.  As  the  toxemia  increases,  the 
headache  becomes  more  severe,  the  stomach  more  irritable,  and  diarrhea 
may  occur.  Associated  with  these  symptoms  there  may  be  a  high-tension 
pulse,  muscular  twitchings,  drowsiness,  and  vertigo;  later,  convulsions  and 
coma  may  occur.  Coma  is  the  most  unfavorable  of  these  symptoms;  per- 
sistent vomiting  associated  with  severe  headache  and  disturbances  of  vision 
are  also  alarming  symptoms.  Since  single  convulsions  not  infrequently 
occur  in  patients  who  make  a  rapid  and  satisfactory  recovery,  this  symp- 
tom cannot  therefore  be  depended  upon  in  making  a  prognosis. 

Urixe. — The  most  important  signs  of  acute  nephritis  are  furnished 
by  an  examination  of  the  urine.  Albumin  is  usually  abundant,  values  of 
over  1  per  cent,  by  weight  being  not  infrequent.  The  urine  in  such  cases 
becomes  dense  with  albumin  on  boiling  or  by  the  addition  of  cold  nitric 
acid.  In  rare  instances  only  a  slight  ring  of  albumin  may  be  present. 
Casts  are  of  more  importance  from  the  standpoint  of  diagnosis  than  is 


ACUTE    MYCOTIC    NEPHRITIS  577 

albumin.  In  all  cases  of  acute  nephritis  they  are  found  in  considerable 
numbers.  Hyalin,  granular,  blood,  and  epithelial  casts  may  be  distributed 
through  the  same  field.  It  should,  however,  especially  be  noted  that  a 
small  amount  of  albumin  and  a  few  hyalin  casts,  without  other  signs  or 
symptoms,  are  not  sufficient  to  make  a  diagnosis  of  nephritis;  these  find- 
ings, as  already  stated,  occur  in  orthostatic  and  toxic  albuminurias,  un- 
associated  with  inflammatory  changes  in  the  kidneys.  The  urine  in  acute 
nephritis,  in  addition  to  an  abundance  of  epithelial,  granular,  and  blood 
casts,  contains  leukocytes,  renal  epithelium  in  various  stages  of  degenera- 
tion, microorganisms,  and  blood  corpuscles.  A  few  red  blood  corpuscles, 
discovered  microscopically,  may  have  little  prognostic  import,  but  the 
presence  of  blood  in  marked  quantities  is  an  unfavorable  sign  and  usually 
indicates  a  severe  form  of  nephritis.  But  in  cases  with  marked  oliguria 
the  hemorrhage  may  somewhat  relieve  the  congested  kidney.  The  prognos- 
tic importance,  however,  of  blood  in  the  urine  depends  upon  its  associa- 
tion with  albumin  and  casts.  In  certain  hemorrhagic  diseases,  such  as 
scurvy,  the  presence  of  blood  may  have  little  prognostic  significance.  In 
acute  nephritis,  urea,  sodium  chlorid,  and  phosphoric  acid  are  diminished. 
The  retention  of  urea  is  an  especially  valuable  indication  of  defective. elim- 
ination. The  amount  of  uric  acid  is  unchanged,  and  the  aloxuric  bases  are 
increased.  The  urine  is  nearly  always  diminished  in  quantity,  is  concen- 
trated, reddish  brown,  or  smoky,  and  has  a  high  specific  gravity,  1,030. 
Occasionally  acute  nephritis  produces  complete  suppression  of  urine ;  this  is 
an  ominous  symptom,  frequently  followed  by  convulsions,  coma  and  death. 

Other  Symptoms. — In  this  connection  it  should  be  remembered  that 
renal  suppression  may  occur,  lasting  over  twelve  or  even  twenty-four  hours, 
in  young  children  who  have  no  other  sign  of  kidney  disease;  complete 
restoration  of  the  kidney  function  quickly  follows  in  these  cases  of  simple 
anuria,  and  they  are  mentioned  here  to  emphasize  the  fact  that  this 
symptom  is  of  serious  import  only  when  it  is  associated  with  the  other 
signs  and  symptoms  of  acute  nephritis. 

Fever  is  an  almost  constant  symptom.  A  rise  in  temperature  during 
apparent  convalescence  from  scarlet  fever,  diphtheria,  and  other  acute  in- 
fectious diseases  should  suggest  nephritis  and  lead  to  an  examination  of  the 
urine.  The  temperature  commonly  runs  between  99°  and  103°  F.  A  sud- 
den rise  during  the  course  of  the  disease  is  a  bad  indication. 

A  marked  secondary  anemia  rapidly  develops,  and  if  the  disease  passes 
into  the  subacute  or  chronic  stage  the  anemia  may  be  an  important  symp- 
tom in  directing  attention  to  the  patient's  condition. 

Complications. — The  most  frequent  complications  are  pleuritis,  endo- 
carditis, pericarditis,  bronchitis,  pneumonia,  meningitis,  and  edema  of 
the  larynx. 

Course  and  Termination. — Acute  primary  nephritis  occurring  in  young 
children  is  a  very  fatal  disease;  in  older  children  recovery  is  the  rule.  If 
these  cases  can  be  tided  over  the  first  week,  a  satisfactory  recovery  may 
be  expected.     In  scarlatinal  and  other  postinfectious  forms  recovery  is 


578  ACUTE  NEPHRITIS 

the  rule,  but  death  may  occur.  It  is  my  experience  that  the  great  majority 
of  these  cases  have  litth'  tendency  to  become  chronic.  The  nephritis  of 
chihlhood  is  a  disease  whicli  has  a  tendency  to  spontaneous  and  com- 
plete recovery.  If  the  patient  lives,  the  kidney,  in  the  vast  majority  of 
instances,  is  restored  to  a  normal  condition.  The  fact,  however,  that 
chronic  nephritis  may,  in  a  small  percentage  of  these  cases,  follow  the 
acute  form  should  ni.ikc  lln'  |»liysi(iaii  tvci-  cMrcful  to  see  that  the  recovery 
from  acute  nepiirilis  is  coiniilctc.  A  |)S(ii(l()  ri'covery  may  mislead  the 
physician  into  withdrawing  the  restrictions  as  to  diet  and  exercise  which 
are  necessary  to  complete  recovery.  The  ordinary  course  of  a  case  of 
acute  nephritis  is  from  three  to  six  weeks,  but  tlu-ivaftcr  tln'  uriuo  should 
be  examined  at  intervals  of  five  or  six  weeks  to  make  sure  that  the  re- 
covery is  complete. 

Prophylaxis. —  In  (he  treatment  of  the  acute  infectious  diseases,  which 
are  so  commonly  followed  by  acute  nephritis,  the  physician  should  ever 
keep  in  mind  the  proi)hylactic  treatment  of  this  condition.  This  especially 
appli(>s  to  scarlet  fever,  dij)htheiia.  and  severe  febrile  attacks  of  acute 
inlluenza.  In  all  of  these  conditions  the  patient  sliould  be  confined  to 
bed,  and  his  body  kept  at  rather  an  even  temperature.  The  diet  should 
be  such  as  to  throw  little  work  on  the  kidney  and  yet  supply  nutritional 
denumds.  Milk,  cereals,  fruit  juices,  and  alkaline  waters  are  especially 
indicated.  When  vegetables  are  allowed  in  the  convaleseenee  from  these 
diseases,  care  should  be  exercised  to  exclude  rhubarb,  tomatoes,  and  as- 
paragus. In  all  the  acute  infections  the  lunvels  shoidd  be  kept  open  by 
saline  or  other  eatharlics,  st)  that  the  kidney  nuiy  not  be  further  irritated 
by  the  elimination  of  intestinal  toxins.  Warm  baths  may  also  be  of  service 
in  promoting  elimination  through  the  skin,  and  thus  diminishing  the 
work  which  the  kidiu'V  is  called  upon  to  do.  The  speeifii'  treatment  of 
various  diseases,  such  as  diphtheria  by  antitoxin,  malaria  by  quinin,  and 
syphilis  by  mercury,  dinunishes  the  dangers  of  nephritis  in  these  diseases. 
Throughout  the  treatment  of  all  acute  diseases,  which  may  be  followed  by 
nejibritis,  the  urine  should  be  frenuently  examined,  so  that  the  nephritis 
uuiy  bo  recognized  (arly  and  cheeked  by  appropriate  treatuu'ut. 

Treatment.— (1i:nkh.\u  Tiikatmknt. — The  first  object  to  he  soiiLihl  is 
the  reestabllsluuent  of  the  kidney  secretion,  if  this  function  has  been 
materially  Interfered  with.  To  accomplish  this  the  kidneys  must  be  rested 
by  withholding  food,  giving  water  and  calling  upon  the  bowels  and  skin  to 
vicarioii' l\  il"  m  portion  of  the  work  of  these  diseased  organs.  Water  is  the 
greatest  oi  all  diuretics  and  is  Indicated  at  all  times  In  all  forms  of  ne- 
phritis. In  beginning  the  treatment  a  saline  cathartic  should  be  prescribed, 
preferably  the  sulphate  of  luagiu'sia ;  Ibis  should  be  givejj  in  suitabh>  doses 
every  three  or  four  hours  until  free  catharsis  has  been  established,  and  dur- 
ing this  tinje  little  water  and  no  food  should  hei  taken.  Sulphate  of  magiu»- 
Hift,  as  n  rule,  produces  less  nausea,  acts  more  quickly  upon  the  bowels,  and 
pUminateH  more  lluid  than  any  other  cathartic.  In  infants  and  young  chil- 
dren milk  of  uuignesla.  Kochelle  salts,  or  a  solution  of  citrate  o(  magnesia 


ACUTE   MYCOTIC    NEPHRITIS  B7» 

mar  be  used.  After  the  bovefe  hare  oaee  keen  nwved.  other  saline  cathartics 
may  be  substituted^  sadi  as  salpliate  of  soda,  phosphate  of  soda,  or  one 
of  the  alkaliBe  cathaitie  miaefal  waters.  Later  in  the  dfeease^  vhtn  the 
acute  symptoms  are  under  control,  vegetable  cathartics,  sneh  as  eiESoara  and 
ciMupound  licorice  powder,  may  be  used  if  the  patient  finds  them  more 
a^lieeabte,  but  throughout  tl»  whole  course  of  the  treatment,  until  actual 
coBTaksceDee  has  been  eBtdblished,  cathartic  nedkation  i%  as  a  rule, 
neeessar;.  In  hi3ruig  stress  upon  the  cathartic  treatment  of  acute  neph- 
ritis it  is  important  to  call  attention  to  the  fact  that,  while  in  the  beginning 
it  must  be  very  active,  in  the  later  treatment  of  the  disuse  care  should 
In?  taken  not  to  weaken  the  patient  or  aggravate  his  anemia  by  unnecessary 
catharsis.  In  all  serere  cases^  in  addition  to  «tfly  cathartic  medication. 
it  is  advisable  to  at  once  begin  to  stimulate  the  skin  to  increased  action. 
This  may  be  done  by  wrapping  the  j)atient  in  blankets  wrun^  ovi  of  hot 
water  (t^mpcfature  110°  F.),  and  surrounding  him  with  hot-water  bottles, 
and  then  coTering  him  with  warm,  dry  blankets;  this  will  produce  copious 
perspiration.  If  the  patient  shows  no  marked  depressing  effects  he  should 
remain  in  this  hot  pack  for  ten  or  fifteen  minutes,  after  which  he  may 
be  wiped  dry  and  covered  with  a  warm,  dry  blanket.  The  copious  sweat- 
ing which  follows  these  measures  is  even  of  greater  value  in  the  relief 
of  profound  uremic  symptoms  than  is  the  cathartic  medioation.  Hot 
packs  are  especially  valuable,  however,  when  nausea  and  vomiting  prevent 
the  cathartic  treatment  above  outlined.  In  such  cases  the  packs  may  be 
-  elemented  by  rectal  injections  of  from  a  pint  to  a  quart  of  normal 
-;i  ae  solution  at  a  temperature  of  105°  F.,  or  the  same  solution  may  be 
used  by  hypodermoclysis,  6  to  1:?  ounces  at  a  dose.  The  following  formula  is 
recommended  by  Martin  H.  Fischer:  "Sodium  chlorid,  14  grams;  sodium 
carbonate  (cr\-stallized),  15  to  30  grams  (not  bicarbonate)  :  water,  1  liter. 
This  solution  is  not  suitable  for  subcutaneous  injection,  but  it  may  be  given 
per  rectum  by  the  drop  method  at  a  temperature  not  below  105°  F.  In 
urgent  cases  it  may  be  injected  intravenously.  For  intra\-enous  use  it  must 
be  sterile.  In  preparing  it,  the  sterile  sodium  chlorid  solution  should  be 
made  first,  and  as  this  is  cooling  the  sodium  carbonate  should  be  added,  as 
heating  the  latter  drives  off  the  CO*.  After  the  formida  has  been  given 
once  by  rectum  or  intravenously  it  is  well  to  wait  three  hours  before  repeat- 
ing the  dose.  It  takes  a  little  time  to  get  the  full  effect  of  the  salt  and  alkali 
on  the  kidney.  As  the  kidney  function  returns,  the  concentration  of  the 
alkali  and  the  salt,  in  subsequent  injections,  may  be  progressively  reduced, 
and  finallv  a  simple  O.J)  per  cent,  sodium  chlorid  solution  by  rectum,  or 
water  salt  and  alkali  by  mouth  will  suffice.'^ 

The  above  formula  is  the  adult  dose  and  is  therefore  to  be  diminished 
proportionately  to  the  age  of  the  child.  At  the  age  of  five,  one-fourth,  and 
at  ten,  caie-half  of  this  dose  should  be  given.  Saline  injections  may  be 
alternated  with  the  hot  packs  at  thret^  or  four-hour  intervals,  until  the 
nausea  ai^  vomiting  have  sufficiently  subsided  to  permit  cathartic  medica- 
tion.    It  should,  however,  be  remembered  that,  while  hot  pa^s  are  life- 


580  ACUTE  NEPHEITIS 

saving  measures  in  the  early  treatment  of  these  severe  cases,  they  are  also 
very  depressing,  and  are  to  be  discontinued  as  soon  as  the  uremic  symptoms 
have  disappeared  and  the  kidney  secretion  is  again  fairly  well  established. 
It  is  rarely  necessary  to  continue  the  hot  packs  for  longer  than  three  or 
four  days,  and  in  the  mild  cases  it  may  not  be  necessary  to  use  them  at 
all.  The  hot  pack  is  also  indicated  and  may  be  of  great  value  in  cases 
where  there  is  considerable  dropsy.  In  these  cases  it  is  to  be  administered 
but  once  in  the  twenty-four  hours,  and  its  effects  are  to  be  carefully 
studied;  if  the  patient  is  feeble  and  the  pack  produces  great  prostration,  it 
may  do  more  harm  than  good.  Dry  cupping,  hot  fomentations,  electric 
heaters,  and  hot-water  bottles  applied  to  the  lumbar  region  may  not  only 
relieve  pain  but  may  also  increase  the  flow  of  urine  by  relieving  congestion 
of  the  kidneys. 

In  very  severe  forms  of  acute  nephritis  with  sudden  onset,  which  are 
comparatively  rare,  the  intoxication  may  be  so  profound  and  the  patient's 
life  may  be  in  such  imminent  danger  that  even  more  radical  measures 
than  those  above  outlined  may  be  indicated  to  control  the  uremia  and  re- 
establish the  kidney  secretion.  In  these  violent  forms  morphin  hypoder- 
mically,  1/10  to  1/50  of  a  grain,  depending  upon  the  age  of  the  child,  may 
be  necessary  to  control  convulsions  and  vomiting;  venesection  should  then 
be  resorted  to,  half  a  pint  to  a  pint  of  blood  being  removed.  Following 
venesection,  sterile  normal  salt  solution,  in  quantities  equal  to  the  amount 
of  blood  removed,  should  be  given  by  subcutaneous  injection,  or  Fischer's 
alkaline  solution  above  noted  should  be  given  intravenously.  Fischer  and 
others  have  reported  very  remarkable  curative  results  in  many  severe  cases 
of  uremia  from  the  use  of  this  alkaline  solution  administered  in  the 
manner  previously  described.  It  is  especially  indicated  in  uremia  and 
severe  acidosis.  When  given  intravenously  it  acts  almost  specifically  in 
controlling  these  symptom  groups.  The  collapse  of  the  veins,  which  occurs 
in  these  conditions  at  times,  makes  the  intravenous  injection  a  very  difficult 
operation. 

Rest  in  bed  is  a  necessary  part  of  the  treatment  of  acute  nephritis  and 
should  be  continued  until  albumin  and  easts  have  disappeared.  If  the 
heart  be  weak  or  the  anemia  pronounced,  albumin  may  recur  in  the  urine 
after  the  patient  is  allowed  to  sit  up  or  be  upon  his  feet.  In  such  cases  it 
is  necessary  to  have  the  child  remain  in  bed  imtil  these  symptoms  are 
controlled  by  appropriate  treatment.  In  some  instances,  where  the  al- 
buminuria is  prolonged,  the  rest-in-bed  treatment  may  become  so  irksome 
to  nervous  children,  especially  in  hot  weather,  that  it  may  be  necessary 
to  place  them  in  reclining  chairs,  and  shift  them  from  beds  to  lounges, 
as  the  judgment  of  the  physician  may  direct.  This  treatment  may  ne- 
cessitate confinement  to  bed  for  five  or  six  weeks;  in  the  average  case, 
however,  this  period  is  much  shorter. 

Dietetic  Treatment. — As  above  noted,  food  should  be  abstained  from 
until  the  bowels  have  been  acted  upon  and  the  nausea  and  vomiting  con- 
trolled.    Following  this,  milk  should  be  the  chief  article  of  diet.     Great 


ACUTE    MYCOTIC    NEPHRITIS  581 

care  should  be  taken  at  all  times  not  to  overload  the  stomach,  or  to  give 
food  at  too  frequent  intervals.  In  the  early  treatment  of  acute  cases  small 
quantities  of  milk,  4  to  6  ounces,  every  five  or  six  hours,  are  all  that  are 
necessary.  After  a  few  days  the  quantity  of  milk  may  be  increased,  but  the 
intervals  between  the  feedings  should  be  maintained.  If  the  child  dislikes 
plain  milk,  then  the  milk  may  be  flavored  or  disguised,  or  one  of  the 
proprietary  milk  foods  substituted.  The  following  are  recommended :  milk 
with  cereal  gruels,  milk  flavored  with  chocolate,  ice  cream  made  from  clean, 
but  not  rich,  milk,  milk  soups,  flavored  in  various  ways,  "malt  soups," 
buttermilk,  malted  milk,  condensed  milk,  and  other  proprietary  milk 
foods.  In  this  list  an  easily  digested  milk  food  may  be  found,  which  the 
child  can  be  induced  to  take,  that  will  serve  nutritional  purposes  and 
remain  the  basis  of  the  child's  diet  throughout  the  disease.  A  little  later, 
as  the  kidney  secretion  becomes  better  established,  fruit  juices,  bread  and 
cereals  may  be  added  to  the  diet.  Orange  juice  and  lemonade  are  espe- 
cially grateful.  As  convalescence  approaches,  potatoes,  and  all  fresh  vegeta- 
bles, except  onions,  rhubarb,  asparagus,  and  tomatoes,  may  be  added  to  the 
diet;  these  latter  are  contraindicated  until  the  child  is  entirely  well.  Small 
quantities  of  meat  and  cooked  eggs  may  be  given  during  early  convalescence, 
but  are  perhaps  better  let  alone  until  the  urine  is  free  from  albumin. 

Fresh  Air. — While  the  temperature  of  the  sick  room  should  be  kept 
uniformly  in  the  neighborhood  of  70°  F.,  the  air  must  always  be  fresh. 
Fresh  air  and  iron  are  the  most  important  agents  we  have  in  combating 
the  anemia  which  is  so  constant  in  this  disease;  the  latter  is  of  special 
value  during  convalescence.  Diuretics  are  for  the  most  part  contraindi- 
cated. During  the  early  stages  of  acute  nephritis,  when  the  kidney  is 
sharply  inflamed,  its  secreting  structures  cannot  be  stimulated  to  increased 
activity  by  such  diuretics  as  the  potash  preparations  or  by  remedies  such 
as  digitalis  that  increase  the  blood  pressure.  In  the  later  stages  of  neph- 
ritis, however,  when  the  inflammation  of  the  kidney  has  largely  subsided 
and  the  heart  is  weak  and  rapid  in  its  action,  digitalis  may  be  of  some 
value;  its  action,  however,  upon  the  "kidney  secretion  as  well  as  upon  the 
heart  should  be  carefully  watched.  Some  alkaline  water  or  plain  water 
is,  as  a  rule,  the  only  diuretic  needed  in  these  cases,  and  after  the  nausea 
and  vomiting  have  subsided  the  child  should  be  urged  to  drink  water.  The 
nervous  or  uremic  symptoms  often  demand  symptomatic  treatment  in 
addition  to  the  hydrotherapy,  catharsis,  and  diet  above  recommended. 
Chloroform,  morphin,  chloral,  and  bromids  may  be  necessary  to  control 
convulsions,  and  bromid  of  potash  and  veronal  may  be  necessary  to  pro- 
duce sleep  and  relieve  nervous  irritation.  I  have  been  much  impressed 
with  the  importance  of  avoiding  excessive  medication  in  these  cases.  Any 
medicine  that  irritates  the  stomach  or  interferes  with  the  appetite  will 
do  more  harm  than  good.  The  treatment  in  the  vast  majority  of  cases 
is  confined  to  diet,  hydrotherapy,  catharsis,  rest  in  bed,  and  fresh  air, 
care  at  all  times  being  taken  to  keep  the  digestive  organs  in  good  con- 
dition. 


582  OTHER    DISEASES    OF   THE   KIDNEYS 

CHAPTER  LXXV 

CHRONIC    NEPHRITIS    AND    OTHER    DISEASES    OF    THE    KIDNEYS 

CHRONIC    NEPHRITIS 

Chronic  nephritis  is  comparatively  rare  in  childhood,  notwithstanding 
the  fact  that  this  is  the  period  of  life  in  which  acute  nephritis  is  most 
common.  Chronic  Bright's  disease  in  the  adult  is  not  commonly  the  se- 
quel of  acute  Bright's  disease;  in  most  instances  it  develops  insidiously, 
and  the  clinical  history  fails  to  trace  the  beginning  of  the  chronic  disease 
to  a  previous  attack  of  acute  nephritis,  which,  through  neglect,  was  al- 
lowed to  develop  into  the  chronic  form.  In  the  child,  however,  this  se- 
quence is  noted;  but,  as  previously  said,  the  tendency  of  acute  nephritis 
in  childhood  is  to  complete  recovery.  We  do,  however,  occasionally  have 
the  same  forms  of  chronic  nephritis  in  children  which  we  have  in  the 
adult,  and  the  symptomatology,  pathology  and  treatment  of  these  chronic 
forms  are  practically  the  same  at  all  ages. 

Chronic  diffuse  non-indurative  nephritis  (chronic  parenchymatous 
nephritis)  may  follow  acute  nephritis  produced  by  scarlet  fever,  influenza, 
syphilis,  and,  less  rarely,  other  causes.  This  form  occupies  an  intermediary 
position  between  acute  nephritis  and  chronic  indurative  nephritis;  all 
three  may  be  stages  of  the  same  pathological  process.  In  acute  and  chronic 
diffuse  nephritis  the  secreting  structures  are  especially  involved  in  the  in- 
flammation. In  the  indurative  form  the  interstitial  tissue  is  also  involved. 
Amyloid  disease  is  a  degenerative  process,  which  may  rarely  be  engrafted 
upon  the  chronic  nephritis  of  childhood.  Marked  amyloid  degeneration 
in  the  child,  as  in  the  adult,  is  usually  associated  with  tuberculosis,  syphilis, 
suppurative  processes,  chronic  malaria,  rickets,  and  diseases  which  produce 
cachexia.  Amyloid  changes  are  not  confined  to  the  kidneys;  other  organs, 
such  as  the  liver,  spleen,  intestines  and  suprarenal  glands,  are  also  involved. 

Symptomatologfy. — The  symptoms  of  chronic  nephritis  in  childhood  are 
the  same  as  the  symptoms  of  chronic  nephritis  in  the  adult,  except  that 
the  disease  is  not,  as  a  rule,  so  insidious.  When  albumin  and  casts  are  dis- 
covered for  the  first  time  in  the  urine,  it  is  important  to  determine  whether 
the  condition  is  a  chronic  one,  and,  if  so,  of  how  long  standing.  If  the 
disease  has  lasted  for  a  year  it  has  passed  beyond  the  acute  stage,  and  it 
is  not  only  unwise,  but  positively  injurious,  to  subject  a  patient  of  this 
kind  to  the  dietetic  and  "rest-in-bed"  treatment  recommended  for  acute 
nephritis;  the  differential  diagnosis  between  acute  and  chronic  nephritis 
is,  therefore,  most  important.  Chronic  nephritis  differs  from  acute  neph- 
ritis in  that  it  is  an  afebrile  disease,  and  the  casts  which  are  found  in 
the  urine,  while  they  are  largely  granular  and  epithelial,  contain  large 
numbers  of  fat  granules,  both  in  and  out  of  the  epithelial  cells,  and  free 
fat   drops  are  commonly  seen.     Red  blood  cells,   if  present  at   all,  are 


CYSTOPYELITIS  583 

scarce;  albiimimiric  retinitis  is  more  common;  eccentric  hypertrophy  of 
the  lieart  with  dilatation  usually  exists.  Anemia  is  more  marked,  and 
the  whole  appearance  of  the  disease  is  that  of  a  chronic  rather  than  an 
acute  process.  Confusion  may  arise  in  the  diflFerential  diagnosis  of  chronic 
from  acute  nephritis  when  the  patient  is  seen  for  the  first  time  with  an 
acute  exacerbation  of  a  chronic  Brighf  s  disease.  In  such  instances  the 
urine  has  the  high  specific  gravity,  the  dark  color,  the  excessive  quantities 
of  albumin,  and  the  microscopic  findings,  including  red  blood  cells  and 
blood  casts,  seen  in  acute  nephritis. 

Treatments — The  treatment  of  all  acute  exacerbations  of  a  chronic 
nephritis  should  be  the  same  as  that  of  acute  nephritis ;  the  milk  diet  and 
rest-in-bed  treatment  are  necessary  in  these  cases  until  the  acute  symp- 
toms are  controlled.  The  treatment  of  chronic  nephritis  is,  however,  very 
different  from  that  of  the  acute  form.  These  patients  should  be  out  of  bed, 
and,  if  the  climate  is  suitable,  in  the  open  air.  If  the  patient  can  take  ad- 
vantage of  climatic  treatment  he  should  live  the  year  around  in  dry, 
warm,  bracing  and  equable  climates;  to  do  this  he  must  necessarily  travel 
with  the  seasons.  Muscular  exercise  to  the  point  of  physical  fatigue  is 
to  be  carefully  avoided. 

The  DIET  is  also  very  different  from  that  of  acute  nephritis.  While 
milk,  buttermilk  and  all  the  milk  foods  recommended  in  the  acute  disease 
should  form  the  basis  of  the  diet,  yet  these  patients  live  much  longer  and 
are  capable  of  accomplishing  much  more  if  they  are  given  a  very  general 
diet.  Fruits,  cereals,  vegetables  and  albumin  should  form  part  of  their 
diet.  Albumin  is  not  only  permissible,  but  is  really  a  very  valuable  food 
in  chronic  nephritis.  It  may  be  given  in  the  form  of  cooked  (never  raw) 
eggs,  fish,  chicken,  mutton,  and  even  beef  in  moderate  quantity  to  suit  the 
individual  case.  Albumin  in  some  form  should  be  given  once  a  day,  but 
care  should  be  taken  that  the  patient  does  not  overeat;  that  is  to  say,  that 
the  number  of  calories  in  the  food  taken  should  not  exceed  that  required 
by  a  normal  individual  of  the  same  weight.  These  patients  should  avoid 
alcohol,  radishes,  asparagus,  onions,  tomatoes,  rhubarb,  and  all  pickled 
and  smoked  foods.  Water  is  never  contraindicated,  even  when  the  urine 
is  scant  and  the  dropsy  is  marked.  In  the  great  majority  of  cases  the  kidney 
secretion  is  comparatively  free,  and  dropsy  is  either  not  present  at  all,  or 
but  slightly  marked.  In  these  cases  ordinary  water,  or  certain  alkaline  and 
lithia  waters,  such  as  Poland  and  Waukesha,  should  be  given  in  large  quan- 
tities. 

Edebohls'  operation  of  splitting  the  capsule  of  the  kidney,  while  not 
curative,  prolongs  the  life  and  adds  greatly  to  the  comfort  of  the  patient. 

CYSTOPYELITIS 

This  condition  is  a  purulent  infection  of  the  urinary  bladder  and 
pelvis  of  the  kidney;  it  is  peculiar  to  infants  and  young  children.  By 
American  and  English  writers  it  is  commonly  described  under  the  term 


584  OTHEK    DISEASES    OF    THE   KIDNEYS 

Pyelitis;  by  the  Germans  it  is  spoken  of  as  Cystitis.  It  is  probable  that 
in  the  vast  majority  of  cases  the  bladder  is  primarily  infected  and  the 
disease  spreads  secondarily  to  the  pelvis  of  the  kidney,  in  some  instances 
involving  the  kidney  structures  (pyelonephritis).  In  a  small  minority 
of  cases,  however,  it  is  known  that  the  infection  begins  in  the  kidney  and 
subsequently  affects  the  bladder,  so  that  perhaps  the  term  cystopyelitis 
most  accurately  describes  this  condition. 

Etiology. — Age  and  sex  are  important  predisposing  factors.  It  may  oc- 
cur in  the  first  weeks  of  life,  but  is  comparatively  rare  before  the  third 
month.  From  this  time  to  the  eighteenth  month  it  is  common,  and  there- 
after diminishes  in  frequency,  up  to  the  sixth  year  of  life.  After  this 
period  cystitis  in  the  child  is  very  similar  in  its  etiology  and  course  to 
cystitis  in  the  adult.  The  predisposition  of  females  is  shown  by  the  fact 
that  only  about  10  per  cent,  of  these  cases  occur  in  males.  Enteritis 
is  the  most  common  predisposing  cause.  It  may  also  follow  influenza, 
scarlet  fever,  diphtheria,  typhoid  fever,  gonorrhea  and  other  forms  of 
vaginitis  and  urethritis.  Stone  in  the  kidney  or  bladder,  congenital  mal- 
formations of  the  urinary  organs,  foreign  bodies,  irritation  of  the  urinary 
organs  by  toxins,  hyperemia  of  these  organs  from  cold  or  other  causes,  and 
retention  of  urine,  are  spoken  of  by  various  writers  as  predisposing 
causes. 

Exciting  Causes. — The  colon  bacillus  is  the  common  exciting  cause. 
This  fact  was  pointed  out  by  Escherich  in  1894;  he  reported  60  cases,  in 
58  of  which  this  bacillus  was  found,  either  in  pure  or  mixed  culture.  These 
findings  have  been  confirmed  by  all  subsequent  observers.  It  may  there- 
fore be  definitely  stated  that  the  ordinary  cystopyelitis  of  infancy  is  due 
to  the  bacillus  coli  communis.  Pfaundler  further  confirmed  this  etiologi- 
cal relationship  by  demonstrating  an  agglutination  reaction  of  these  bacilli 
with  the  blood  serum  of  a  patient  sick  with  this  disease.  Other  micro- 
organisms, however,  may  produce  a  purulent  cystopyelitis.  Among  these 
the  following  may  be  mentioned :  bacillus  proteus  vulgaris,  bacillus  lactis 
aerogenes,  staphylococci,  streptococci,  gonococci,  and  typhoid,  tubercle, 
pyocyaneus,  and  diphtheria  bacilli. 

Infection  in  the  vast  majority  of  cases  occurs  from  below  upward 
through  the  urethral  canal.  In  these  cases  cystitis  is  probably  the  primary, 
and  pyelitis  the  secondary,  lesion;  this  is  especially  true  of  infection  by 
the  colon  bacillus.  Infection  may  occasionally  occur  through  the  blood 
stream,  primarily  affecting  the  kidney.  The  infecting  microorganisms  may 
also  migrate  directly  through  intervening  tissues  from  the  intestinal  canal 
to  the  urinary  organs.  The  two  latter  modes  of  infection,  however,  are 
comparatively  rare,  so  that  from  a  clinical  standpoint  it  is  well  to  recognize 
the  fact,  not  only  that  the  vast  majority  of  these  cases  are  caused  by  colon 
bacilli,  but  that  these  infecting  organisms  commonly  find  an  entrance 
through  the  urethral  canal  to  the  urinary  bladder  and  later  to  the  kidney. 
With  these  facts  in  mind  one  can  understand  why  this  disease  occurs  so 
frequently  in  young  female  infants  whose  urethral  canals  are  exposed  to 


CYSTOPYELITIS  585 

contamination  from  fecal  discharges,  and  also  why  this  disease  is  so  com- 
monly the  sequel  of  enteritis. 

Symptomatology. — General  Symptoms. — Local  symptoms,  such  as 
pain  and  tenderness  over  the  bladder  and  frequent  and  painful  urination, 
may  lead  to  the  discovery  of  this  condition  through  an  examination  of  the 
urine.  In  the  majority  of  cases  local  symptoms  on  the  part  of  the  genito- 
urinary organs  are  either  not  present  at  all,  or  are  so  slight  as  to  be  over- 
looked. In  this  fact  lies  the  difficulty  of  diagnosis,  or  rather,  one  should 
say,  it  explains  why  this  condition  is  so  commonly  overlooked.  The  diag- 
nosis of  these  cases  is  simple  enough  where  the  symptoms  are  such  as  to 
cause  the  physician  to  make  a  urine  examination,  but  since  routine  exam- 
inations of  the  urine  of  infants  are  not  commonly  made  in  private  practice 
he  depends  upon  the  constitutional,  rather  than  the  local,  symptoms  to 
direct  his  attention  to  the  location  of  this  infection.  An  unexplained  fever 
is  the  most  notable  and  constant  of  these  constitutional  symptoms.  It  is 
commonly  associated  with  more  or  less  gastrointestinal  disturbance  and 
frequently  with  the  following  symptoms:  restlessness,  nervous  irritability, 
anorexia,  nausea,  abdominal  colic,  pain  and  tenderness  over  the  bladder, 
and  a  more  or  less  marked  and  progressive  pallor.  If  physicians  would 
examine  the  urine  of  every  infant  suffering  from  a  fever  the  cause  of 
which  was  not  clearly  defined,  but  few  of  these  cases  would  be  overlooked. 

The  fever  in  cystopyelitis  is  usually  continuous,  showing  marked  re- 
missions. It  may,  however,  be  intermittent  or  septic  in  character,  rising 
to  104°  or  105°  F.,  and  falling,  within  twenty-four  hours,  below  normal. 
In  acute  cases  the  fever  is  important,  both  from  the  standpoint  of  diagnosis 
and  prognosis;  the  bad  cases  are  marked  by  high  and  irregular  fever  and 
a  cessation  of  the  febrile  process  usually  means  approaching  convalescence. 
In  mild  cases  the  febrile  reaction  may  be  slight.  Chronic  cases  may  con- 
tinue for  an  indefinite  period  with  little  or  no  elevation  of  temperature. 

In  very  severe  cases  the  clinical  'picture  may  be  even  more  obscured 
and  attention  may  be  directed  away  from  the  urinary  tract  by  symptoms 
resembling  typhoid  fever,  pneumonia,  severe  intestinal  intoxication  or 
meningitis.  That  this  disease  does  occasionally  present  the  appearance 
of  tlie  above-named  infections  is  a  fact  which  should  be  kept  in  mind. 
Mistakes  in  diagnosis  can  be  prevented  only  by  systematic  urine  examina- 
tions in  all  infectious  processes  characterized  by  pronounced  constitutional 
symptoms. 

In  chronic  cases  this  disease  may  be  complicated  by  the  coexistence  of 
the  symptom-complex  elsewhere  described  as  recurrent  vomiting.  I  have 
seen  cases  of  this  kind,  such  as  are  reported  by  Porter  and  Fleischner. 

A  tender  tumor  in  the  kidney  region  may  sometimes  be  found  by 
palpation.  This,  as  a  rule,  indicates  a  pyelonephritis  or  a  pyelitis,  in 
which  the  pus  is  distending  the  pelvis  of  the  kidney.  In  these  cases  the 
fever  curve  is  high  and  intermittent;  that  is  to  say,  markedly  septic  in 
character,  and  the  other  constitutional  symptoms  are  much  aggravated. 
Convulsions  and  other  uremic  symptoms  may  intervene  in  the  fatal  cases. 


586  OTHER    DISEASES    OF   THE   KIDNEYS 

Urine. — The  diagnosis  is  made  by  the  urine  findings.  Pus  cells  in 
great  numbers,  as  well  as  renal  (caudate)  and  bladder  (squamous)  epithe- 
lium, are  found.  A  small  quantity  of  albumin  and  occasional  casts,  hyalin 
and  granular,  are  present  in  many  of  the  cases.  The  specific  microorgan- 
isms causing  the  disease  may  be  discovered  if  the  proper  technique  is  used. 

The  urine  in  the  majority  of  these  cases  is  acid  in  reaction ;  this  is  true 
in  all  cases  produced  by  the  colon  bacillus,  and  in  the  extremely  rare  cases 
produced  by  the  tubercle  bacillus.  It  is  alkaline  in  reaction  when  the  dis- 
ease is  produced  by  septic  cocci.  In  the  more  severe  cases  where  the  kidney 
structure  is  involved  the  filtered  urine  contains  much  albumin,  and  a 
microscopic  examination  shows  many  epithelial,  granular  and  blood  casts; 
blood  corpuscles  may  also  be  found. 

In  chronic  cases  an  X-ray  picture  may  be  of  value  in  determining  the 
size  of  the  kidney,  and  the  presence  or  absence  of  a  kidney  stone. 

Course  and  Termination. — A  small  percentage  terminate  fatally  as  a 
result  of  kidney  involvement  or  general  sepsis.  In  about  95  per  cent,  the 
prognosis,  so  far  as  life  is  concerned,  is  favorable,  and  the  tendency,  as  a 
rule,  is  to  spontaneous  and  complete  recovery.  A  considerable  number  of 
the  cases  which  ultimately  recover  pass  from  the  acute  to  the  subacute 
form  of  this  disease  and  continue  for  many  months  or  even  years. 

Prognosis. — Thf  prognosis  depends  largely  upon  the  character  of  the 
initial  infection.  The  colon  cases  are  the  most  favorable;  these  most  com- 
monly terminate  in  recovery  in  from  two  to  eight  weeks.  Cases  in  which 
septic  cocci  predominate  are  more  prolonged,  more  severe  and  more  dan- 
gerous. If  diphtheria  bacilli  are  found,  the  disease  is  even  more  serious, 
and  the  finding  of  tubercle  bacilli  usually  justifies  an  unfavorable  prog- 
nosis. It  should  be  remembered  that  simple  cases,  due  primarily  to  colon 
bacilli,  may  by  neglect  or  maltreatment  be  converted  into  severe  and  dan- 
gerous cases  of  mixed  infection,  in  which  the  septic  cocci  play  the  most 
important  role. 

Relapses  may  occur  in  cases  that  have  apparently  recovered;  Abt  re- 
ports two  relapses  in  twenty  cases ;  one  of  these  had  three  attacks. 

Prophylaxis.— The  prophylactic  treatment  consists  in  keeping  the  geni- 
tal organs  of  the  infant  clean,  by  changing  the  diaper  and  carefully  wash- 
ing and  drying  the  external  genitalia  as  soon  after  the  discharge  of  fecal 
matter  as  possible,  the  object  being  to  prevent  the  colon  bacillus  from  en- 
tering the  urethral  canal.  Vaginitis  and  urethritis  in  the  infant  and 
young  child  should  receive  prompt  and  careful  attention. 

Treatment. — Some  of  the  milder  cases  require  little  treatment  other 
than  quiet,  cleanliness,  and  careful  attention  to  diet.  Enteritis  when 
present  should  receive  attention.  Alkaline  waters  are  valuable  diuretics. 
Citrate  of  potash,  recommended  by  Holt,  in  3-  to  5-grain  doses  three  times 
a  day,  is  of  value.  One  tablespoonful  of  a  saturated  solution  of  sodium 
phosphate  in  every  bottle  or  glass  of  milk  I  have  found  of  great  service  in 
chronic  cases  associated  with  constipation.  Bicarbonate  of  soda  may  also 
be  given  in  the  food. 


TUMOES    OF    THE    KIDNEY  587 

TJrotropin  is  perhaps  our  most  valuable  remedy  during  the  acute  stage. 
It  may  be  given  three  times  a  day,  in  from  one-  to  three-grain  doses,  de- 
pending upon  the  age  of  the  child;  it  is  an  effective  urinary  antiseptic, 
which  materially  assists  in  shortening  the  course  of  the  disease.  In  some 
instances,  as  Abt  has  noted,  this  drug  may  cause  "renal  and  vesicle  irri- 
tation"; it  is  then  contraindicated.  Salol  is  a  valuable  remedy,  especially 
in  young  infants;  it  may  be  given  three  times  a  day,  in  two-  to  five-grain 
doses,  according  to  the  age  of  the  child,  without  disturbing  the  gastro- 
intestinal tract;  it  acts  as  a  mild  urinary  antiseptic.  Guaiacol,  which  is 
excreted  largely  through  the  urine,  acts  like  urotropin  and  salol  as  a  uri- 
nary antiseptic ;  it  is  especially  valuable  in  very  young  infants.  It  may  be 
given  in  the  form  of  the  carbonate  in  two-  to  four-grain  doses  three  times 
a  day,  or  in  liquid  form  it  may  perhaps  better  be  administered  by  inunc- 
tion. For  this  purpose  one  drachm  of  liquid  guaiacol  is  combined  with 
one  ounce  of  anhydrous  lanolin,  and  one  drachm  of  this  ointment  is  thor- 
oughly rubbed  into  the  skin  of  the  abdomen  or  axillary  regions  once  a  day 
(see  chapter  on  General  Therapeutics). 

Both  autogenous  and  stock  bacillus  call  vaccines  have  been  used  very 
successfully  in  these  cases.  This  vaccine  treatment  should,  therefore,  be 
tried  in  cases  that  fail  to  respond  in  a  reasonable  time  to  the  above-named 
measures. 

Irrigation  of  the  bladder  is,  as  a  rule,  inadvisable  and  unnecessary; 
in  refractory  cases,  however,  it  may  be  resorted  to.  For  this  purpose  a 
weak  solution  of  nitrate  of  silver,  1-2,000,  or  a  saturated  solution  of 
boracic  acid  are  recommended.  High  temperatures  may  be  treated  by  ice- 
bags  to  the  head  and  sponging  with  cold  water.  In  those  rare  cases  where 
the  X-ray  locates  a  stone  or  other  foreign  body  in  the  urinary  passages 
surgical  intervention  is  necessary. 

TUMORS  OF  THE  KIDNEY 

Sarcoma  is  by  far  the  most  common  of  kidney  tumors.  Osier  says 
that  nearly  all  large,  solid,  abdominal  tumors  in  children  are  sarcomatous. 
Birch-Hirschfeld  describes  these  malignant  tumors  of  the  kidney  under 
the  term  embryonal  adenosarcomata,  and  believes  that  primary  carcino- 
mata  are  relatively  rare.  From  a  clinical  standpoint  further  classification 
than  this  is  unnecessary,  since  all  malignant  tumors  of  the  kidney  have 
practically  the  same  etiology,  symptomatology,  prognosis  and  treatment. 
Usually  only  one  kidney  is  involved,  the  left  more  frequently  than  the 

right. 

Etiology.— Little  or  nothing  is  known  of  the  causative  factors.  Chronic 
irritations,  from  traumatic  causes,  are  said  to  precede  the  formation  of 
tumors  in  many  cases.  They  have  their  origin  in  embryonal  tissues,  and, 
as  they  develop,  the  kidney  structure  is  gradually  destroyed  by  compres- 
sion ;  they  push  out  from  the  region  of  the  kidney  downward  and  inward, 
until  in  time  they  may  fill  the  entire  abdominal  cavity.     In  their  early 


588  OTHER    DISEASES   OF   THE   KIDNEYS 

development  the  kidney  alone  may  be  involved,  but  late  in  the  disease 
metastasis  may  occur,  involving  the  liver,  lymph  nodes,  and  other  organs; 
the  bladder,  however,  is  rarely  affected.  These  tumors  may  be  present  in 
the  new-born ;  the  great  majority  of  them  occur  during  the  first  five  years ; 
they  are  very  rare  after  the  tenth  year. 

Symptomatology. — The  tumor  is  the  characteristic  symptom;  in  most 
instances  it  develops  insidiously.  Attention  may  be  called  to  this  condition 
by  the  appearance  of  blood  in  the  urine,  but,  as  a  rule,  enlargement  of  the 
abdomen  is  the  first  symptom  noticed,  and  a  physical  examination  then 
reveals  the  tumor.  In  its  early  stages  it  may  be  unilateral,  and  may  be 
felt  protruding  from  the  region  of  the  kidney  downward  and  inward  into 
the  abdominal  cavity;  later  it  may  become  so  large  as  to  produce  great 
abdominal  distention  so  symmetrical  that  a  physical  examination  may 
with  difficulty  discover  which  kidney  is  involved.  Small  tumors,  discov- 
ered early,  are  firm  and  solid ;  large  ones  are  soft  and  doughy  to  the  touch. 
These,  when  they  have  reached  a  size  where  they  can  be  easily  palpated. 


Fig.  86. — Sarcoma  of  the  Kidney:  Infant  Four  Months  Old.     (J.  F.  Bell.) 

grow  rapidly,  and  should  not  be  mistaken  for  enlargement  of  the  liver  or 
spleen.  Both  of  these  organs,  when  enlarged,  produce  a  board-like  smooth 
tumor,  the  edge  of  which  can  be  sharply  outlined  by  palpation  and  per- 
cussion; this  is  not  true  of  malignant  growths.  The  location  of  the  dis- 
tended colon  running  along  and  above  these  tumors  may  be  made  out 
and  is  of  importance  from  the  standpoint  of  differentiation,  particularly 
from  enlargements  of  the  spleen  and  liver. 

Hematuria  is  a  common  and  early  symptom  which  is  said  to  occur 
more  frequently  in  carcinoma.  The  blood  may  be  so  abundant  as  to  be 
made  out  by  the  naked  eye;  in  most  instances,  however,  the  microscope 
reveals  the  hemorrhage.  Pain  is  a  common  but  not  a  characteristic  symp- 
tom ;  it  may  be  severe,  but  is  usually  dull,  producing  discomfort  and  irri- 
tability. As  the  tumor  becomes  very  large  pressure  symptoms  appear,  and 
displacements  of  the  abdominal  viscera  are  common.  In  the  later  stages 
cachexia,  emaciation  and  loss  of  strength  are  pronounced  symptoms.  As- 
cites and  swelling  of  adjacent  lymph  nodes  are  also  present.  When  both 
kidneys  are  involved,  uremic  symptoms  may  mark  the  closing  stages  of 
the  disease. 


CYSTIC  DEGENERATION  OF  THE  KIDNEY  589 

Treatment. — The  complete  removal  of  these  tumors  by  surgical  meas- 
ures is  advised  in  all  cases  where  cachexia  and  profound  nutritional  dis- 
turbances do  not  exist;  about  70  or  75  per  cent,  survive  the  operation; 
6  or  7  per  cent,  of  these  ultimately  recover,  and  those  that  do  not  recover 
are,  for  the  time  being,  made  more  comfortable  and  life  is  prolonged.  If 
the  operation  is  made  while  the  tumor  is  yet  small  and  confined  to  the 
kidney,  the  prognosis  is  much  more  favorable.  The  symptomatic  medical 
treatment  of  these  cases  consists  in  making  the  patient  as  comfortable  as 
possible  by  relieving  pain  and  nervous  irritability  by  the  judicious  use  of 
phenacetin,  aspirin,  or  some  preparation  of  opium,  such  as  paregoric, 
codein  or  morphin. 

HYDRONEPHROSIS 

Hydronephrosis  in  children  is  a  comparatively  rare  condition.  It  is  com- 
monly congenital,  but  there  is  an  acquired  form,  which  may  occur  late  in 
childhood. 

Etiology. — It  is  due  to  obstruction  in  some  part  of  the  urinary  canal, 
commonly  the  ureters ;  in  rare  instances  the  stenosis  may  occur  lower  down 
in  the  bladder  or  urethra.  The  blocking  of  the  urinary  canal  may  be  caused 
by  calculi,  inflammatory  adhesions,  malformations,  twisting  of  the  ureters 
and  tumors.  These  mechanical  obstructions  impede  or  prevent  the  flow 
of  urine  through  the  urinary  canal,  and  this  results  in  an  accumulation  of 
fluid  in  the  pelvis  of  the  kidney,  which  gradually  produces  a  fluctuating 
tumor.     The  pressure  of  this  fluid  may  destroy  the  kidney  substance. 

Symptomatology. — The  characteristic  symptom  is  a  fluctuating  tumor 
which  may  be  large  enough  to  extend  downward  and  inward  from  the  region 
of  the  kidney  well  into  the  abdominal  cavity.  Aspiration  of  this  tumor 
obtains  an  albuminous  fluid,  containing  urates,  urea,  and  epithelium. 
Hydronephrosis  is  usually  unilateral;  when  bilateral,  it  early  terminates 
fatally. 

Treatment. — When  hydronephrosis  is  unilateral,  and  the  urine  dis- 
charged shows  that  the  other  kidney  is  normal,  radical  surgical  measures 
for  the  removal  of  the  diseased  kidney  are  justifiable.  Such  cases  are 
very  rare  and  are  more  commonly  found  in  the  acquired  form  in  older 
children. 

CYSTIC  DEGENERATION  OF  THE   KIDNEY 

Cystic  degeneration  of  the  kidney  is  congenital  and  almost  always 
bilateral.  By  the  development  of  cysts  in  the  kidney  structure  the  func- 
tional efficiency  of  these  organs  is  destroyed,  and  the  infant  dies  from 
uremia.  This  condition  is  fortunately  rare,  and  is  of  little  interest  except 
from  the  standpoint  of  diagnosis.  Congenital  cystic  kidneys  are  palpable 
at  birth. 


590  OTHER    DISEASES    OF    THE    KIDXP^YS 


TUBERCULOSIS   OF   THE   KIDNEY 

Tuberculosis  of  the  kidney  is  almost  always  a  secondary  condition. 
The  diagnosis  is  made  by  the  symptoms  and  signs  of  tuberculosis  elsewhere 
in  the  body  and  by  the  finding  of  tubercle  bacilli  in  the  urine.  The  urinesj 
of  these  cases  usually  contain  red  blood  cells,  albumin  and  pus.  Pro- 
gressive anemia,  loss  of  weight  and  strength,  an  irregular  temperature 
curve,  and  other  symptoms  of  tuberculosis  are  usually  present. 


PERINEPHRITIS 

Perinephritis  is  an  inflammation  of  the  tissue  in  which  the  kidney  is 
imbedded;  it  is  a  rare  condition,  commonly  terminating  in  abscess.  The 
disease  is  secondary  to  tuberculosis,  or  pyogenic  infections  in  the  kidney 
or  elsewhere  in  the  body.  Traumatism  is  classed  as  an  important  etiological 
factor.  It  is  important  to  keep  in  mind  that  perinephritic  abscesses,  al- 
though rare,  may  occur,  and  that  the  pus  may  burrow  downward,  forming 
a  fluctuating  mass  beneath  the  liver  or  the  spleen.  In  these  cases  there 
is  tenderness  on  pressure  in  the  lumbar  region,  and,  on  deep  pressure, 
bimanual  examination  may  reveal  a  soft  tumor.  Chills,  fever,  and  the 
symptoms  of  septicopyemia  are  present.  The  treatment  of  this  condition 
is  surgical. 

DISLOCATION  OF  THE   KIDNEY 

Both  the  kidney  and  suprarenal  glands  are  relatively  large  in  infancy; 
at  birth  the  suprarenals  are  nearly  one-third  the  size  of  the  kidneys.  The 
kidney  itself  is  1/100  of  the  body  weight,  while  in  the  adult  it  is  about 
1/230,  so  that  at  birth  it  is  relatively  more  than  twice  as  large  as  in  the 
adult.  The  lobulated  form  of  the  fetal  kidney  persists  for  a  short  time 
after  birth.  Notwithstanding  the  relatively  large  size  of  the  kidney  at 
this  period  of  life,  it  cannot  be  palpated,  nor  can  it  be  readily  located  by 
percussion.  A  kidney,  therefore,  that  can  be  palpated  at  or  shortly  after 
birth  may,  as  a  rule,  be  classed  as  a  congenital  dislocation.  There  are  two 
types  of  this  deformity:  the  floating  kidney,  which  is  rare  in  infancy,  and 
dystopia  or  downward  displacement  of  the  kidney,  which  is  still  more  rare. 
In  the  latter  condition  the  kidney  is  not  more  movable  than  normal,  but  is 
found  well  down  in  the  abdomen.  This  displaced  kidney  is  commonly  lobu- 
lated and  its  ureter  is  short. 


GONORRHEAL   VULVOVAGHSTITIS  591 

CHAPTER    LXXVI 

DISEASES     OF    THE    GENITAL    OEGANS 

GONORRHEAL  VULVOVAGINITIS 

Gonorrheal  vulvovaginitis  in  infants  and  young  children  differs  from 
the  gonorrhea  of  the  older  child  and  adult,  in  that  it  is  rarely  a  venereal 
disease.  It  is  caused  by  the  accidental  inoculation  of  the  vulvovaginal 
canal  with  the  gonococcus  of  Neisser.  It  is  confined  exclusively  to  female 
infants  and  young  female  children.  The  corresponding  condition,  gonor- 
rheal urethritis,  is  very  rare  in  the  male  infant  and  child.  It  occurs  in 
extensive  and  at  times  almost  uncontrollable  epidemics  in  institutions  for 
infants  and  young  children.  In  this  tendency  to  spread  in  epidemic  form 
without  sexual  contact,  it  is  wholly  unlike  gonorrhea  in  the  adult;  it  also 
manifests  itself  in  a  less  virulent  form,  and  has  fewer  complications.  In 
recent  years  it  has  become  much  more  prevalent,  so  that  at  the  present 
time  it  can  usually  be  discovered  in  all  large  institutions  caring  for  female 
children.  Holt  finds  that  5  per  cent,  of  cases  applying  for  admission  to 
the  Babies'  Hospital  in  New  York  have  this  disease.  It  is  also  not  uncom- 
monly seen  in  private  practice.  Holt  graphically  describes  the  difficulties 
of  combating  it  in  hospital  practice,  and  notes  the  fact  that  273  cases 
occurred  within  five  years  in  the  Babies'  Hospital,  in  spite  of  "the  united 
efforts  of  the  physicians  and  superintendents  in  quarantine  and  disinfec- 
tion." 

Etiology. — Institutional  epidemics  can  usually  be  traced  to  the  admis- 
sion of  a  case  of  this  disease  into  a  ward  containing  other  children.  It 
is  then  rapidly  spread  by  means  of  bathtubs,  diapers,  underclothing,  bed- 
linen,  thermometers,  and  other  things  that  may  carry  the  contagion  from 
the  infected  child  to  the  genital  tracts  of  other  children.  Holt  has  espe- 
cially dwelt  upon  the  fact  that  the  nurses'  hands  may  frequently  carry  this 
contagion.  It  is  the  testimony  of  all  physicians  who  have  studied  the  spread 
of  these  epidemics  in  very  young  children  that  in  some  indirect  way  the 
genital  tracts  are  readily  inoculated  with  the  contagion  when  it  exists  in 
the  ward,  and  also  that  it  is  almost  impossible  to  prevent  the  spread  of 
this  disease  if  the  infected  child  is  allowed  to  remain  in  the  ward,  or  to 
associate  in  any  way  with  well  children.  It  may  occur  in  the  new-born; 
in  such  cases  the  vaginal  canal  of  the  infant  is  inoculated  during  birth 
by  the  vaginal  discharges  of  the  mother.  The  great  majority  of  cases  occur 
between  the  third  and  fifth  year  of  life.  It  wi\l  thus  be  seen  that  the 
vaginal  canal  of  the  young  child  is  remarkably  susceptible  to  this  con- 
tagion, and  it  is  believed  by  many  writers  that  scarlet  fever  (Alice  Ham- 
ilton), measles,  and  possibly  other  acute  infections  render  them  even  more 
susceptible.  The  writer  in  1906  reported  an  epidemic  occurring  in  a 
diphtheria  ward,  but  he  attributed  the  spread  of  the  disease  to  overcrowd- 
39 


592  DISEASES   OF   THE   GENITAL    ORGANS 

ing  rather  than  to  an  increased  predisposition  produced  by  diphtheria. 
Gonorrheal  vaginitis  occurring  in  ohler  children,  from  seven  to  twelve 
years  of  age,  may  be  due  to  sexual  contact,  or  it  may  result  from  the  child 
sleeping  in  the  same  bed  with  an  adult  who  has  this  disease.  These  cases, 
both  in  their  etiology  and  clinical  course,  more  closely  resemble  the  disease 
as  it  occurs  in  the  adult. 

Symptomatology. — In  the  great  majority  of  cases  the  disease  is  discov- 
ered accidentally,  there  being  no  subjective  symptoms  to  call  attention  to 
disease  of  the  genital  tract.  The  vaginal  discharge  is  the  all-important 
sign.  It  may  be  so  slight  as  to  be  almost  unrecognizable,  or  so  copious  as 
to  stain  the  napkins,  underclothing  or  bed-linen.  It  commonly  has  the 
appearance  of  mucopus;  in  some  cases  it  may  be  glairy  and  tenacious;  in 
others  it  may  be  thin,  yellowish,  greenish,  and  tinged  with  blood.  In 
aggravated  cases  small  ulcerations  may  occur.  The  experience  of  recent 
years  has  demonstrated  that  the  vast  majority,  perhaps  95  per  cent.,  of 
severe  cases  of  vaginitis  occurring  in  young  children  is  due  to  the  gono- 
coccus,  or  at  least  one  may  say  that  in  such  cases  a  microorganism,  which 
cannot  be  differentiated  from  the  gonococcus  of  Neisser,  is  found.  In 
practically  all  of  these  cases,  however,  the  gonococcus  is  associated  with 
other  microorganisms,,  such  as  are  found  in  cases  of  so-called  simple  vagi- 
nitis; among  these  may  be  mentioned  streptococci,  staphylococci,  colon 
bacilli  and  pseudodiphtheritic  bacilli.'  The  ultimate  diagnosis  in  these 
cases  is  made  by  the  demonstration  of  gonococci  in  the  vaginal  discharges. 
This  demonstration  is  commonly  made  by  finding  the  gonococci  within  the 
pus  cells.  The  failure  of  these  cocci  to  decolorize  under  Gram's  method  of 
staining  is  considered  characteristic.  In  long-standing  cases,  as  Heimann 
and  others  have  pointed  out,  gonococci  may  be  demonstrated  only  by  cul- 
ture methods. 

In  mild  cases  there  may  be  very  little  swelling  of  the  labia  and  vagina, 
but  in  others  these  parts  may  be  red,  swollen  and  much  irritated.  In 
some  instances  the  child  complains  of  discomfort,  and  painful  urination 
may  indicate  that  the  urethra  is  involved.  The  inflammation  may  be 
limited  to  the  vagina  in  the  early  stages,  but  in  the  great  majority  of  cases 
it  is  probable,  as  Koplik  insists,  that  the  cervix  uteri  is  also  inflamed,  and 
this  is  especially  true  of  children  over  six  years  of  age.  In  infants  and 
very  young  children  the  disease  is  probably  more  frequently  confined  to 
the  vagina.  In  children  over  seven  years  of  age  the  inflammation  is  usu- 
ally more  severe,  the  secretion  more  copious,  the  parts  more  swollen  and 
the  Fallopian  tubes,  as  w^ell  as  the  uterus,  more  likely  to  be  involved ;  these 
are  the  cases  which  may  possibly  produce  sterility  in  after  life.  Suppura- 
tion of  the  inguinal  glands  may  rarely  occur  in  older  children.  This 
condition  is,  for  the  most  part,  an  afebrile  disease,  but  in  some  cases  during 
the  most  acute  stage  the  temperature  rises  to  101  °F.  In  long-continued 
cases  nutrition  may  suffer;  this  is  probably  due  to  the  confinement,  and 
lack  of  fresh  air  and  exercise,  which  the  treatment  entails. 

Complications. — Complications    are    comparatively    rare.     I    treated    a 


GONORRHEAL    VULVOVAGINITIS  593 

series  of  40  cases  in  the  Cincinnati  Hospital  without  a  single  complica- 
tion. During  this  time,  however,  three  cases  of  gonorrheal  conjunctivitis 
were  admitted ;  in  all  of  them  there  was  a  coexistent  vaginitis.  The  litera- 
ture of  this  subject  shows  that  the  following  complications  may  occur: 
conjunctivitis,  arthritis,  endo-  and  pericarditis,  stomatitis,  peritonitis,  cys- 
titis and  proctitis;  of  these,  conjunctivitis  is  by  far  the  most  common. 
Holt  reports  26  cases  of  acute  gonococcus  arthritis,  19  of  which  were  in 
male  infants,  and  only  three  presented  at  any  time  any  other  evidences 
of  gonorrheal  infection;  two  were  associated  with  vaginitis. 

Prognosis.  — Nearly  all  of  these  cases  finally  get  well ;  very  few  of  them 
terminate  fatally.  The  course  of  this  disease  is,  as  a  rule,  tedious;  it 
usually  continues  for  from  one  to  four  months,  and  may  last  for  years; 
relapses  are  common  in  cases  apparently  cured.  Occasionally  an  eye  may 
be  lost,  and  sterility  may  possibly  result  in  older  children. 

Prophylaxis. — The  prophylactic  measures  necessary  to  prevent  the 
spread  of  this  disease  in  institutions  which  care  for  female  children  may 
be  outlined  as  follows :  All  female  children  applying  for  admission  should 
be  carefully  examined,  and  if  there  be  the  slightest  evidence  of  vulvo- 
vaginal irritation  or  catarrh  they  should  be  kept  carefully  isolated  until 
repeated  microscopical  examinations  of  their  vaginal  secretions  have  demon- 
strated the  presence  or  absence  of  the  gonococcus.  The  fact  that  the  vast 
majority  of  these  cases  of  vaginal  catarrh  sooner  or  later  show  the  pres- 
ence of  the  gonococcus  has  caused  most  clinicians,  who  have  had  experi- 
ence with  this  disease  in  institutions,  to  exclude  all  cases  of  this  kind  from 
children's  wards,  even  though  the  gonococcus  cannot  be  demonstrated. 
This  latter  plan  is  perhaps  the  safest  rule  to  follow,  since  the  non-gonor- 
rheal  cases  are  also  infectious.  During  an  epidemic  it  is  wise  to  set  apart 
a  ward  where  all  infected  cases  may  be  at  once  isolated  from  those  not 
having  the  disease.  Infected  children  should  wear  diapers  holding  pads 
of  gauze  covering  the  genitalia,  and  these  pads  should  be  changed  fre- 
quently, and  destroyed  by  burning.  All  clothing,  linen,  etc.,  should  be 
soaked  in  bichlorid  solution  before  they  are  sent  to  the  wash.  Nurses 
should  be  carefully  instructed  as  to  the  danger  of  carrying  the  infection 
on  their  hands  and  thus  producing  conjunctivitis,  or  reinoculating  the 
vaginal  canals  of  convalescent  children.  To  avoid  these  dangers  the  nurse 
should  thoroughly  cleanse  and  disinfect  her  hands  after  giving  the  treat- 
ment or  handling  infected  clothing.  The  ward  bathtub  should  not  be  used 
for  bathing  purposes,  and  the  toilets  should  be  carefully  cleansed  after 
each  individual  use.  Each  patient  should  be  provided  with  a  separate 
catheter  and  other  instruments  used  in  the  treatment,  and  following  the 
treatment  these  should  be  carefully  cleansed  and  placed  in  separate  bottles 
containing  carbolic  acid  solution  and  labeled  with  the  child's  name. 

Treatment.  — The  most  important  part  of  the  treatment  is  the  thorough 
douching  twice  a  day  of  the  vaginal  canal  with  large  quantities  of  some 
non-irritating  alkaline  antiseptic.  In  my  experience  the  degree  of  success 
will  depend  not  alone  upon  the  care  which  is  exercised  in  avoiding  injury 


594  DISEASES   OF   THE   GENITAL    OEGAXS 

to  the  inflamed  parts,  but  also  on  the  character  of  the  instrument  used  for 
carrying  the  antiseptic  solution  into  the  vagina.  The  small  female  catheter, 
which  is  almost  universally  recommended,  is  not  at  all  suited  for  this 
purpose,  since  the  blunt  end  of  the  catheter  pushes  the  discharge  ahead  of 
it  to  a  point  high  up  in  the  vagina,  quite  out  of  reach  of  the  antiseptic 
solution  which  passes  through  the  eye  of  the  catheter.  After  a  long  and 
unsuccessful  use  of  this  and  other  instruments,  I  conceived  the  idea  of 
having  this  same  small-sized  female  catheter  perforated  at  the  end  and  an 
additional  hole  made  in  the  opposite  side,  so  that  there  would  be  three 
openings  through  which  the  antiseptic  fluid  might  escape  in  irrigating  the 
vagina.  The  hole  in  the  end  of  the  catheter  is  of  the  greatest  importance, 
as  it  allows  thorough  irrigation  of  the  cervix  of  the  uterus  and  the  vault 
of  the  vagina.  It  is  also  important  that  the  catheter  used  should  be  small 
enough  to  insert  with  ease  into  the  vagina,  and  the  nurse  should  be  in- 
structed to  exercise  great  care  in  its  use,  so  that  the  slightest  trauma  to 
the  parts  may  be  prevented.  In  1906  I  recorded  my  success  with  this 
method  of  treatment,  and  since  that  time  I  have  been  more  and  more  im- 
pressed with  the  fact  that  attention  to  details,  as  above  outlined,  is  abso- 
lutely necessary  to  success. 

In  my  experience  the  best  irrigating  solution  is  normal  salt  solution 
containing  5  to  10  per  cent,  of  boracic  acid;  of  this  two  or  three  quarts 
are  to  be  used  night  and  morning,  to  be  followed  by  the  injection  through 
the  same  catheter  of  three  ounces  of  a  1  per  cent,  solution  of  nitrate  of 
silver.  As  the  inflammation  subsides  the  strength  of  the  nitrate  of  silver 
solution  may  be  increased  to  2  or  3  per  cent.  This  is  to  be  continued 
for  ten  days  after  the  discharge  has  ceased  and  gonococci  are  no  longer 
found.  The  patient  should  then  be  transferred  to  another  ward  and  kept 
under  observation  for  ten  days  or  two  weeks  without  treatment.  If  at  the 
end  of  that  time  there  is  no  return  of  the  vaginal  discharge  and  no  gono- 
cocci are  found,  the  patient  may  be  finally  discharged. 

Other  irrigating  solutions,  such  as  a  weak  solution  of  permanganate 
of  potash,  or  a  saturated  solution  of  boracic  acid,  have  been  widely  recom- 
mended in  these  cases,  and  10  to  40  per  cent,  solutions  of  argyrol  have 
also  been  successfully  used,  following  the  antiseptic  douche.  My  experi- 
ence with  the  vaginal  douche  above  outlined  has  been  very  large,  and  I 
have  never  seen  bad  results  follow  its  use,  and  am,  therefore,  inclined  to 
think  its  value  is  so  great,  and  the  risk  of  infecting  the  cavity  of  the  uterus 
so  slight,  that  it  should  unhesitatingly  be  used  in  all  cases. 

A^ACCiNE  Treatment. — Investigations  have  shown  that  these  cases  may 
be  benefited  by  vaccine  treatment,  but  it  is  advisable  in  each  case  to  deter- 
mine the  opsonic  index  of  the  individual  before  the  treatment  is  begun, 
in  order  that  the  value  of  the  vaccine  injections  may  be  correctly  deter- 
mined. Alice  Hamilton  made  a  careful  study  of  this  treatment  and  came 
to  the  following  conclusion:  "Better  results  are  obtained  by  the  use  of 
strains  which  have  been  grown  for  a  long  period  on  artificial  media  than 
by  the  use  of  freshly  isolated  strains,  and  there  appears  to  be  no  advan- 


UEETHBITIS    IN    MALE    CHILDREN  595 

tage  in  using  the  patient's  own  organism.  While  the  inoculation  treat- 
ment does  not  produce  a  marked  effect  during  the  first  weeks  in  acute 
cases,  it  seems  to  shorten  the  later  stages;  in  chronic  cases  its  effects  are 
more  evident  than  in  acute.  It  is  desirable,  though  not  absolutely  essen- 
tial, to  control  the  inoculation  by  the  patient's  opsonic  index." 

SIMPLE   VULVOVAGINITIS 

Koplik  states  that  this  condition  is  not  infrequent,  and  that  the  local 
symptoms  are  very  similar  to  the  gonorrheal  form  of  this  disease.  The 
differential  diagnosis  between  the  two  is  made  by  the  presence  or  absence 
of  the  gonococcus  in  the  vaginal  discharges.  The  great  majority  of  other 
writers  have  found  simple  vaginitis  in  children  under,  six  years  of  age  to 
be  a  comparatively  rare  disease.  Only  about  5  per  cent,  of  the  well-marked 
cases  of  vaginitis  belong  to  this  class;  in  95  per  cent,  the  gonococcus  is 
found  some  time  or  other  in  the  course  of  the  disease.  In  children  over 
six  years  of  age,  however,  a  simple,  mild,  vaginal  catarrh  is  not  so  infre- 
quent. 

Etiology. — It  is  believed,  especially  in  older  children,  that  general  mal- 
nutrition and  the  acute  infections  may  predispose  to  this  disease;  tuber- 
culosis, anemia,  measles,  influenza,  and  scarlet  fever  may  be  etiological 
factors.  Among  the  exciting  causes  the  following  have  been  named: 
dirt,  foreign  bodies,  pin  worms,  scabies,  masturbation,  and  traumas  from 
any  cause.  The  inflammation  is  maintained  by  streptococci,  staphylococci, 
colon  bacilli,  pseudodiphtheritic  bacilli,  and  perhaps  other  microorganisms. 
One  or  more  of  these  bacteria  may  be  demonstrated  in  the  vaginal  dis- 
charge. The  diagnosis  of  simple  vaginitis  depends  not  alone  upon  the 
presence  of  a  mucopurulent  discharge,  but  upon  the  failure  to  demonstrate 
gonococci  in  this  discharge.  The  local  symptoms  differ  from  those  of  true 
gonococcus  vaginitis  only  in  the  severity  of  the  inflammatory  process.  The 
labia  and  vagina  are  red  and  swollen  and  covered  with  a  mucous  or  puru- 
lent secretion,  and  the  catarrhal  process  may,  in  severe  cases,  involve  the 
cervix.     The  urethra  may  also  be  involved,  producing  painful  micturition. 

Course  and  Treatment. — These  cases  yield  more  readily  to  treatment 
than  those  of  gonococcus  vaginitis;  they  may  commonly  be  brought  under 
control  within  two  or  three  weeks.  The  local  treatment  is  the  same  as  that 
outlined  for  gonococcus  vaginitis.  If  tuberculosis,  anemia,  or  other  forms 
of  malnutrition  be  present,  these  conditions  should  receive  appropriate 
treatment,  and  ofttimes  the  cure  of  the  local  condition  waits  upon  the  cure 
of  the  underlying  constitutional  trouble. 

URETHRITIS  IN  MALE  CHILDREN 

Simple  urethritis  resulting  from  uncleanliness  and  infection  may  occur 
in  young  children.  The  meatus  is  swollen  and  inflamed,  and  on  pressure 
a  few  drops  of  pus  may  exude  from  the  urethra.    Urination  is  more  or  less 


596  DISEASES   OF   THE   GENITAL    ORGAXS 

painful.  The  condition  yields  readily  to  treatment.  The  external  part" 
are  to  be  kept  clean,  dusted  with  an  antiseptic  powder.  Salol  and  bi- 
carbonate of  potash  sliould  be  given  internally. 

Gonorrheal  urethritis  occurring  in  older  boys  has  the  same  etiology  and 
treatment  as  in  the  adult. 

ADHERENT    PREPUCE 

Adherent  prepuce  is  due  to  an  agglutination  of  the  epithelial  layers 
of  the  glands  and  prepuce;  it  is  present  in  nearly  every  male  infant.  The 
treatment  consists  in  forcibly  retracting  the  prepuce,  separating  the  ad- 
hesions, removing  the  retained  smegma  and  anointing  the  parts  with  vase- 
lin.  This  procedure  is  to  be  repeated  at  intervals  of  a  few  days,  until  there 
is  no  longer  any  .tendency  to  agglutination  of  the  mucous  meml)ranes. 
From  time  to  time  throughout  infancy  and  early  childhood  this  process 
may  have  to  be  repeated. 

PHIMOSIS 

Phimosis  may  result  from  a  long  and  thickened  prepuce,  from  a  con- 
genital narrowness  of  the  preputial  orifice  and  from  inflammation  of  the 
parts  (balanitis). 

Symptomatology. — Phimosis  is  very  common;  in  many  cases  the  child 
suffers  no  inconvenience  and  symptoms  calling  attention  to  the  condition 
may  be  absent;  in  others  the  parts  may  be  inflamed  and  irritated  and  the 
passage  of  urine  causes  pain  and  increased  irritation.  Where  the  opening 
is  very  small  the  urine  may  have  difficulty  in  escaping,  and  balloon- 
ing of  the  prepuce  may  occur  with  urination;  in  these  cases  the  re- 
tention and  decomposition  of  the  urine  may  add  to  the  irritation  and  pro- 
duce a  balanitis.  Phimosis  not  infrequently  induces  priapism,  and  in- 
fantile masturbation  may  result.  It  is  also  one  of  the  most  common  reflex 
factors  of  such  neurotic  disturbances  as  night  terrors,  incontinence  of 
urine,  general  nervous  irritability,  hysteria  and  sleeplessness. 

Treatment. — In  mild  cases  the  preputial  orifice  should  be  dilated,  the 
foreskin  retracted,  the  agglutinated  surfaces  of  the  mucous  membranes 
separated,  the  smegma  carefully  removed  and  the  parts  anointed  with  vase- 
lin  or  some  other  ointment.  This  process  is  to  be  repeated  from  time  to 
time  until  the  preputial  orifice  is  fully  dilated  and  the  mucous  membranes 
are  no  longer  in  a  condition  of  irritation  that  will  result  in  their  agglutina- 
tion. In  cases  where  this  procedure  is  not  followed  by  success,  or  in  those 
cases  in  which  the  prepuce  is  very  long  and  the  preputial  orifice  is  very 
narrow,  circumcision  should  be  resorted  to.  Circumcision  is  very  much  to 
be  preferred  to  the  dilation  treatment  if  the  latter  has  to  be  continued 
over  a  long  period  of  time. 

PARAPHIMOSIS 

Paraphimosis  is  a  complication  which  sometimes  occurs  in  phimosis 
when  the  foreskin,  retracted  over  the  glands,  becomes  strangulated  in  this 


HYPOSPADIAS  597 

position.  It  is  characterized  by  marked  edema  of  the  strangulated  prepuce 
and  congestion  of  the  glands.  In  some  cases  this  strangulation  may  be 
overcome  by  pressure  upon  the  glands  in  such  a  manner  as  to  force  it 
through  the  constriction.  If  this  manipulation  fails  the  constriction  must 
be  relieved  by  a  surgical  operation  and  circumcision  may  be  performed  at 
the  same  time. 

HYDROCELE 

Hydrocele  is  an  accumulation  of  fluid  in  the  peritoneal  sac  surround- 
ing the  testicle  and  epididymis.  In  the  congenital  variety  there  is  a  direct 
communication  between  the  hydrocele  sac  and  the  peritoneal  cavity,  and 
the  fluid  may  be  pressed  upward  and  made  to  disappear  in  the  abdominal 
cavity.  In  true  hydrocele  of  the  tunica  vaginalis  the  upper  portion  of 
the  hydrocele  sac  is  closed,  and  the  tumor  cannot  be  made  to  disappear  by 
pressure;  in  this  condition  a  well-marked  oval  tumor  is  present,  either  on 
one  or  both  sides  of  the  scrotum.  Fluctuation  may  be  made  out,  and  the 
illumination  test  may  ditferentiate  the  testicle  from  the  more  translucent 
hydrocele  fluid.  In  hydrocele  of  the  cord  the  tumor  extends  upward  and 
is  elongated;  an  encysted  hydrocele  of  the  cord  occurs  when  the  hydrocele 
fluid  is  held  in  this  position  between  two  constrictions. 

Treatment.  — Hydrocele  in  infancy  usually  disappears  without  treat- 
ment. If,  however,  the  condition  persists,  the  fluid  may  be  drawn  off  by 
puncturing  the  sac;  should  the  tumor  recur  from  time  to  time,  the  with- 
drawal of  the  fluid  may  be  followed  by  the  injection  of  1  or  2  drops  of 
tincture  of  iodin,  in  the  hope  that  the  irritation  following  this  procedure 
will  obliterate  the  sac.  If  the  congenital  form  persists,  a  truss  may  be  worn 
to  facilitate  adhesions  in  the  canal  which  communicates  with  the  abdom- 
inal cavity. 

UNDESCENDED   TESTICLE 

The  testicles  are  usually  found  in  the  scrotum  at  or  shortly  after  birth. 
In  rare  instances,  however,  the  testicle  does  not  descend ;  it  may  remain  in 
the  inguinal  canal  or  in  the  abdominal  cavity.  The  diagnosis  is  made  by 
an  examination  of  the  parts  which  results  in  flnding  the  scrotum  empty 
on  one  side,  rarely  on  both,  and  a  small  tumor,  the  size  of  the  infantile 
testicle,  in  the  inguinal  canal.  Undescended  testicle,  as  a  rule,  requires 
no  treatment  unless  it  be  so  caught  in  the  inguinal  canal  as  to  be  pressed 
upon  and  give  rise  to  pain  and  irritation.  Under  these  conditions  surgical 
treatment  may  be  necessary  to  remove  the  testicle  from  its  position  in 
the  canal  into  the  abdominal  cavity,  or,  if  possible,  to  its  normal  position 
in  the  scrotum. 

HYPOSPADIAS 

Hypospadias  is  a  congenital  deformity  of  the  male  genital  organs,  in 
which  the  urethra  does  not  extend  to  its  normal  orifice  in  tlie  head  of  the 


598  DISEASES   OF   THE   GENITAL    ORGANS 

penis.  It  opens  on  the  under  surface  of  this  organ  at  some  point  between 
the  base  of  the  scrotum  and  the  end  of  the  penis.  Beyond  the  opening  the 
urethra  may  be  represented  by  an  open  fissure  extending  some  distance 
along  the  inferior  surface  of  the  penis.  In  severe  cases  the  opening  may 
occur  in  the  perineal  region,  producing  a  fissure  which  extends  beneath 
the  scrotum,  and  because  of  the  rudimentary  condition  of  the  penis  and 
undescended  testicle,  which  are  not  infrequently  associated  with  this  con- 
dition, it  may  be  mistaken  for  hermaphrodism.  The  incontinence  of  urine 
which  occurs  in  these  cases  is  a  source  of  great  annoyance  and  results  in 
more  or  less  irritation  of  the  parts.  In  the  milder  cases  surgical  inter- 
vention may  partially  overcome  this  deformity. 

EPISPADIAS 

Epispadias  is  a  very  rare  malformation  in  which  the  urethra  opens 
on  the  upper  surface  of  the  penis  and  beyond  this  opening  a  furrow  may 
extend  to  the  glans. 

ENURESIS 

Enuresis  in  children  is  a  symptom  usually  neurotic  in  origin.  It  is  not, 
as  a  rule,  associated  with  a  muscular  incompetency  of  the  sphincter 
vesicae.  The  cases  of  incontinence  of  urine  due  to  malformations  and 
paralysis  are  not  included  under  this  heading.  Enuresis,  like  the 
other  neuroses  of  childhood,  commonly  rests  upon  a  tripod  of  etio- 
logical factors,  viz. :  1,  irritable  and  unstable  nerve  centers  due  to 
age  and  heredity;  2,  bad  blood  and  consequent  malnutrition;  3,  re- 
flex irritation.  In  many  cases  these  three  factors  coexist.  It  is  not 
wise,  without  a  most  careful  examination  of  the  individual  case,  to 
assume  that  any  one  of  these  factors  is  the  sole  cause  of  this  condition. 
A  rational  inquiry  into  the  etiology  of  a  case  of  enuresis  must  seek  for 
the  presence  or  absence  of  each  of  these  factors,  and  must  determine  their 
relative  importance  in  producing  this  syndrome. 

The  detrusor  muscles  of  the  bladder,  which  by  their  contraction  expel 
its  contents,  and  the  sphincter  muscle,  which  by  its  contraction  prevents 
the  escape  of  urine  from  the  bladder,  are  enervated  by  sensory  and  motor 
nerves  from  the  lumbar  cord.  The  bladder  is  emptied,  or  its  contents  re- 
tained, according  to  the  paths  through  which  the  nervous  impulse  from 
the  lumbar  center  is  carried.  Another  most  important  fact  to  bear  in 
mind  is  that  while  the  urination  center  in  the  spinal  cord  may  be  excited 
to  discharge  its  impulses  from  reflex  excitation,  it  is,  to  a  large  extent, 
in  normal  children,  under  the  inhibitory  control  of  higher  centers,  includ- 
ing the  voluntary  centers  in  the  brain  cortex.  This  inhibitory  function 
of  the  higher  centers  exercises  a  marked  control  over  the  discharge  of 
nerve  force  to  the  bladder  from  the  urination  center  in  the  cord ;  the  act 
of  urination  is,  for  this  reason,  largely  under  the  control  of  inhibitory 


ENURESIS  599 

centers  and  partly  nnder  control  of  the  will.  We  will  to  urinate  or  not 
to  urinate,  and  the  message  passes  down  to  the  center  in  the  lumbar  cord 
where,  by  the  mechanism  just  described,  the  bladder  is  emptied  or  its  con- 
tents retained. 

Etiology. — The  etiological  factors  of  enuresis  may  also  be  divided  with 
reference  to  the  manner  of  their  action,  into  three  classes:  First,  those 
that  act  upon  the  higher  centers,  diminishing  their  inhibitory  control  over 
the  urination  center  in  the  lumbar  cord ;  second,  those  that  act  directly  on 
this  center  in  the  cord,  making  it  more  irritable  and  unstable,  and  in  that 
way  increasing  its  reflex  excitability;  third,  those  that  act  by  reflex  irri- 
tation indirectly  on  the  spinal  centers,  touching  off  the  nervous  impulses 
which  produce  urination. 

Predisposing  Causes. — Age  is  a  most  important  predisposing  factor. 
In  early  life  the  nerve  centers  are  more  excitable  and  reflex  phenomena 
of  all  kinds  are  greatly  exaggerated,  and  in  addition  to  this  there  is  a 
functional  immaturity  of  the  centers  inhibiting  reflex  acts.  In  early  in- 
fancy inhibition  is  so  feebly  developed  that  we  have  a  normal  incontinence 
of  urine.  As  the  infant  grows  older  the  mechanism  inhibiting  reflex  acts, 
becomes  better  developed,  so  that  by  training  it  may  acquire  fair  control 
of  the  bladder  during  waking  hours,  about  the  seventh  or  eighth  month  of 
life;  but,  during  sleep,  incontinence  of  urine  may  continue,  even  in  the 
normal  child,  through  the  second  year;  after  the  third  year  it  should  be 
considered  pathological.  The  delayed  development  of  the  mechanism 
which  controls  urination,  in  the  great  majority  of  instances,  does  not  per- 
sist beyond  the  seventh  year,  but  enuresis  from  various  causes  may  continue 
into  adult  life. 

Heredity. — A  neurotic  inheritance  is  an  important  predisposing  cause 
of  enuresis.  It  may  manifest  itself  as  a  family  tendency,  and  children 
with  enuresis  not  infrequently  have  other  nervous  symptoms. 

Chronic  malnutritions  due  to  tuberculosis,  improper  feeding,  unhy- 
gienic surroundings,  enteritis,  rheumatism,  malaria  and  syphilis  are  po- 
tent factors  in  producing  enuresis.  Influenza  and  other  acute  infections, 
by  interfering  with  the  child's  general  nutrition,  may  prolong  or  cause 
a  recurrence  of  enuresis.  Children  of  gouty  parents  who  have  inherited  a 
marked  uric  acid  diathesis,  not  infrequently  suffer  from  this  condition.  As 
Williams  has  noted,  a  thyroid  insufficiency  may  also  produce  enuresis. 

Exciting  Causes. — Reflex  irritation  in  some  form  is  such  an  impor- 
tant exciting  cause  of  enuresis  that  it  can  be  found  in  about  half  of  the 
cases.  The  reflexes  which  are  most  closely  associated  with  enuresis  have 
their  origin,  as  a  rule,  in  genital,  vesicle  and  rectal  irritations.  The  most 
important  reflex  causes  are  phimosis,  preputial  adhesions,  contraction  of, 
or  granulations  in,  the  meatus,  vaginitis,  urethritis,  hyperacidity  of  the 
urine,  an  excess  of  oxalates  and  urates  in  the  urine,  bacteriuria  (com- 
monly due  to  colon  bacilli),  cystitis,  calculi,  contracted  and  intolerant 
bladder,  thread  worms,  fissure  and  eczema  of  the  anus,  and  rectal  polypi. 
Reflex  irritations  having  their  origin  in  diseases  of  distant  organs  such  as 


600 


DISEASES   OF    THE   GENITAL    OHGAXS 


the  throat,  nose,  eye  and  intestinal  canal,  may  be  associated  with  enuresis, 
and  the  removal  of  these  distant  reflex  causes  of  irritation  may  exercise 
a  favorable  influence  on  the  course  of  the  disease. 

Habit. — It  should  be  remembered  that  whatever  may  have  been  the 
important  etiological  factors  of  enuresis,  the  condition  may  continue  even 
after  they  are  ajjparently  removed.  The  continuance  of  the  enuresis  in 
these  cases  may  in  part  be  due  to  the  spinal  irritability  Avhich  still  per- 
sists, but  it  may  be  due  to  the  habit  which  has  been  formed  of  emptying 
the  bladder  when  it  cor  tains  but  a  small  quantity  of  urine;  this  habit  is 
apparently  engrafted  upon  the  nervous  mechanism  which  controls  urina- 
tion. 

Kuhrah  offers  the  following  table  as  a  summary  of  the  causes  of  noc- 
turnal enuresis : 

Physiological — Taking  too  much  fluid. 


Eliminative , 


Urine. 


Genitourinary  organs. 


Nervous  system. 


General . 


Due  to  faulty  metabolism. 
Eating  too  much  salt,  etc. 
Due  to  drugs. 

Hyperacidity. 

Alkalinity. 

Bacteriuria. 


Urethritis. 

Cystitis. 

Pyelitis. 


Inflammations. . 

Malformations. 

Calculi. 

Tumors  or  polypi. 

Hypertrophy. 

Hypertonia  or  irritability  of  bladder. 
Weakness  of  sphincter. 

Balanitis. 

Vulvovaginitis. 
Eeflex J    Anal  fissure. 

Rectal  polypi. 

Intestinal  parasites. 
Malformation  of  spinal  cord. 
General  irritability. 

Diabetes  mellitus. 

Diabetes  insipidus. 

Eachitis. 

Thyroid  insufficiency. 

Enlarged  adenoids  and  tonsils. 


ENURESIS  601 

Symptomatology. — Enuresis,  in  about  55  per  cent,  of  the  cases,  occurs 
only  at  night.  About  40  per  cent,  are  both  nocturnal  and  diurnal,  and 
about  5  per  cent,  are  diurnal  only.  Incontinence  of  urine  may  occur  once 
or  several  times  during  the  night,  or  in  milder  cases  days  or  weeks  may 
intervene.  Nocturnal  incontinence  occurs  most  commonly  soon  after  the 
child  goes  to  bed;  at  this  time  sleep  is  most  profound.  Enuresis,  not 
being  due  to  paralysis,  or  lack  of  development  of  sphincter  muscles,  does 
not  have  as  one  of  its  symptoms  dribbling  of  the  urine;  on  the  other  hand, 
the  contraction  of  the  bladder  empties  this  organ  as  thoroughly  as  under 
normal  conditions. 

The  urine  should  be  examined  with  reference  to  increased  acidity  and 
the  presence  of  bacteria,  crystals,  and  other  causes  of  bladder  irritation; 
infection  with  the  colon  bacillus  is  a  not  uncommon  cause. 

Prognosis.— The  prognosis  as  to  ultimate  recovery  in  nearly  all  cases 
is  good.  The  great  majority  can  be  cured  by  careful  systematic  treatment 
within  a  period  of  two  to  six  months.  Even  untreated  cases,  as  a  rule, 
recover  by  the  seventh  year  of  life.  A  small  percentage  resist  all  methods 
of  treatment,  and  may  persist  even  into  adult  life. 

Treatment. — General  Treatment. — In  the  treatment  of  no  other 
neurosis  of  childhood  is  it  of  more  importance  to  remove  every  possible 
cause  of  reflex  irritation.  It  is  a  waste  of  time  to  begin  medical  or  other 
treatment  until  a  most  careful  search  for  reflex  factors  has  been  made. 
Phimosis  should  be  relieved  by  circumcision,  or  by  stretching  the  prepuce 
and  carefully  uncovering  the  glans;  an  adherent  or  contracted  prepuce 
must  not  be  allowed  to  persist.  Genital,  vesicle  and  rectal  irritations, 
from  the  causes  previously  named,  should  be  removed  by  appropriate  medi- 
cal or  surgical  treatment,  and  sources  of  reflex  irritation  in  the  throat, 
nose  and  eye  should  receive  attention.  Digestive  disturbances  of  all  kinds 
should  be  removed  by  proper  medication. 

The  diet  in  all  cases  is  important,  even  though  the  intestinal  functions 
be  normal.  It  is  a  good,  general  rule  to  exclude  sweets,  pastry,  coffee,  tea, 
beef  juice,  beef  tea,  and  alcohol.  The  amount  of  nitrogenous  food  stuffs 
must  be  regulated  to  suit  the  individual  case.  Well-nourished  children 
of  gouty  diathesis,  having  a  tendency  to  acid  urine  and  high  specific 
gravity,  should  be  given  meat  and  eggs  sparingly,  but  with  children  suf- 
fering from  tuberculosis  and  other  forms  of  chronic  malnutrition  these 
foods  are  indicated.  In  this  latter  class  of  cases  tonics,  such  as  cod-liver 
oil,  iron  and  arsenic,  may  be  of  value,  and  fresh  air,  night  and  day,  is 
important. 

The  child  should  be  protected  from  excitement  and  nervous  strain; 
should  not  be  permitted  to  go  to  school;  should  be  put  to  bed  early  and 
should  have  the  whole  routine  of  his  daily  life  carefully  regulated.  He 
should  neither  be  punished  nor  threatened  with  punishment  for  wetting  the 
bed.  He  should,  however,  be  made  to  understand  the  importance  of  over- 
coming this  habit  by  retaining  his  urine  for  as  long  a  time  as  possible 
during  the  day.    If  the  child  can  be  taught  to  accustom  the  bladder  to  hold 


602  DISEASES   OF   THE   GENITAL   ORGAXS 

considerable  quantities  of  urine  for  some  hours  during  the  day,  the  habit 
on  the  part  of  the  bladder  of  discharging  urine  when  only  partly  filled  may 
not  be  carried  over  into  the  night. 

In  nocturnal  incontinence  of  urine  the  child  should  take  as  little  fluid 
as  possible  after  four  o'clock  in  the  afternoon,  and  should  be  awakened  to 
empty  his  bladder  about  an  hour  and  a  half  after  going  to  bed.  The  foot 
of  the  bed  should  be  raised  so  that  the  child's  shoulders  will  be  lower  than 
his  hips,  and  he  should,  if  possible,  be  prevented  from  sleeping  on  his  back ; 
incontinence  of  urine  does  not  occur  so  readily  when  the  child  sleeps  upon 
his  side  or  stomach.  A  cold  douche  to  the  spine,  once  a  day,  may  act  as  a 
tonic  to  the  irritable  spinal  cord  and  assist  in  the  cure  of  certain  trouble- 
some cases  of  enuresis;  it  may  not,  however,  be  well  borne  in  nervous, 
malnourished  children. 

Medical  Treatment. — Belladonna  is  the  one  drug  which  all  writers 
recommend,  and  it  is,  without  doubt,  of  great  value.  It  should  be  remem- 
bered that  belladonna  may  be  given  in  comparatively  large  doses  to  chil- 
dren, and  that  to  get  results  the  dose  -must  be  gradually  increased  until 
the  enuresis  is  controlled,  or  until  pronounced  physiological  symptoms, 
such  as  dilatation  of  the  pupils,  dryness  of  the  throat,  or  redness  of  the 
skin,  are  produced.  In  this  event  the  drug  is  to  be  discontinued  and  subse- 
quently administered  in  smaller  doses.  For  a  child  of  six  years  one  may 
begin  with  a  dose  of  three  minims  of  the  tincture  three  times  a  day; 
after  three  or  four  days  the  quantity  may  be  increased  one  drop  a  day,  until 
physiological  symptoms  are  produced,  or  until  the  child  is  taking  twenty- 
five  or  thirty  drops  in  twenty-four  hours.  Holt  says :  "A  convenient 
method  of  administration  is  to  use  a  solution  of  atropin,  1  grain  to  gii  of 
water,  of  which  one  drop  (1/1,000  of  a  grain)  may  be  given  for  each  year 
of  the  child's  age.  For  nocturnal  incontinence  this  dose  should  at  first 
be  given  at  four  and  ten  p.  m. ;  after  a  few  days  at  four,  seven  and  ten  p.  m. 
Usually  this  may  be  gradually  increased  until  double  the  quantity  is  given. 
A  child  of  five  years  would  then  be  taking  ten  drops  (1/100  of  a  grain) 
at  each  of  the  hours  mentioned.  I  have  rarely  found  it  advisable  to  go 
above  these  doses." 

If  the  symptoms  are  benefited  or  controlled  by  the  belladonna  treatment 
this  drug  should  be  continued  in  smaller  doses  (one-half  the  size  of  the 
maximum  dose)  for  months,  or  until  the  incontinence  of  urine  has  been 
controlled  for  a  period  of  two  or  three  weeks,  and  thereafter  one  dose 
should  be  given  at  bedtime  for  a  period  of  four  or  five  weeks.  The  bella- 
donna treatment  creates  a  tolerance  on  the  part  of  the  bladder  which  en- 
ables it  to  hold  larger  quantities  of  urine,  and  thereby  materially  assists 
in  overcoming  the  habit  of  frequent  urination. 

Alkalies  are  indispensable  in  the  treatment  of  cases  in  which  there  is 
a  marked  uric  acid  diathesis,  and  in  which  there  is  an  excess  of  urates 
and  acids  in  the  urine.  In  these  cases  the  belladonna  should  be  given  with 
benzoate  of  soda,  or  bicarbonate  of  potash  or  soda,  and  this  prescription 
may  be  made  more  palatable  by  the  addition  of  peppermint  water  com- 


DEFINITION    AND    SYMPTOMATOLOGY  603 

bined  with  some  simple  elixir.  For  a  child  of  six  years,  five  grains  of 
either  of  these  alkalies  may  be  given  after  meals.  It  is  better  to  prescribe 
the  alkali,  and  the  belladonna,  or  atropin,  in  separate  bottles,  so  that  the 
dose  of  the  belladonna  may  be  increased  without  increasing  the  alkali.  In 
children  having  a  periodic  tendency  to  a  return  of  acid  urine  these  al- 
kalies should  be  given  over  a  long  period  of  time. 

.  Constipation,  which  is  frequently  present,  may  be  overcome  by  a  daily 
dose  of  phosphate,  or  sulphate  of  soda,  given  in  carbonate  waters  to  cover 
its  taste. 

In  nervous,  hysterical  children,  not  of  the  acid  urine  type,  bromid  of 
potash  given  at  bedtim.e  may  be  combined  with  the  belladonna  treatment. 
It  is,  as  a  rule,  not  advisable  to  continue  the  bromid  treatment  for  more 
than  a  week  or  ten  days. 

"Strychnin  has  been  very  widely  recommended  in  the  treatment  of 
troublesome  cases  of  enuresis.  It  is  perhajis  of  most  value  in  those  cases 
in  which  the  incontinence  occurs  during  the  day  as  well  as  during  the 
night.  It  should  be  combined  with  the  belladonna  treatment.  It  is  per- 
haps contraindicated  in  nocturnal  incontinence  occurring  in  children  hav- 
ing an  exaggerated  reflex  irritability. 

Urotropin  in  i/^-  to  1-grain  doses  three  times  a  day  is  of  decided  value 
in  those  cases  having  a  highly  acid  urine  produced  by  a  colon  infection 
of  the  urinary  tract. 

Williams  has  noted  the  fact  that  a  small  group  of  cases  respond  readily 
to  the  judicious  use  of  thyroid  therapy.  He  recommends  that  undersized 
children  having  a  subnormal  temperature,  a  poor  peripheral  circulation 
and  presenting  a  high  arched  palate,  adenoids  and  enlarged  tonsils  and 
who  do  not  respond  to  other  methods  of  treatment  should  be  given  y^  grain 
of  dried  thyroid  twice  a  day.  In  suitable  cases  a  marked  improvement 
occurs  within  a  week  and  a  cure  rapidly  follows.  Williams  further  notes 
that  with  the  disappearance  of  the  enuresis  the  child  rapidly  gains  in 
weight. 


CHAPTEE   LXXVII 

PSEUDOMASTURBATION    IN    INFANTS* 

Definition  and  Symptomatology. — Pseudomasturbation  is  a  syndrome 
in  infancy  and  early  childhood  which  has  been  described  in  medical  litera- 
ture under  the  titles,  "Thigh  Friction"  and  "Infantile  Masturbation."  It 
is  commonly  accomplished  with  the  child  lying  on  its  back;  the  thighs 
are  flexed,  crossed  and  pressed  tightly  together,  closely  embracing  the  ex- 
ternal genitalia ;  in  this  position  the  infant  makes  a  wriggling,  or  up-and- 
down  body  movement,  and  rubs  its  thighs  together.  In  other  instances 
^This  chapter  is  taken,  with  slight  modifications,  from  the  author's  paper  on 
this  subject  in  the  Archives  of  Pediatrics,  August,  1907. 


604 


PSEUDOMASTURBATION    IN    INFANTS 


OENlTAU 


y^LUANTOlS 


the  genitalia  are  rubbed  with  the  hands  or  feet,  or  against  some  piece  of 
furniture  or  other  foreign  object.  These  movements  are  apparently  at- 
tended by  a  pleasurable  excitement;  the  face  is  flushed  and  there  is  a 
marked  increase  in  the  general  nervous  tension.  Following  this  act,  which 
continues  for  a  few  minutes  only,  there  is  general  relaxation,  accompanied 
by  mild  perspiration,  quiet  contentment,  and,  in  some  instances,  sleep. 
These  attacks  may  occur  many  times  in  twenty-four  hours,  or  days  or 
weeks  may  intervene  between  them. 

Etiology. — Age  is  the  most  important  etiological  factor.  In  the  fe- 
male the  urinary  bladder,  the  rectum  and  the  external  genitalia,  includ- 
ing the  clitoris,  the  labia  majora  and  labia  minora,  are  all  derived  from 
the  same  membrane,  viz.,  the  mesoderm  of  the  allantois  and  cloaca.  In 
the  male  analogous  structures  are  derived  from  the  same  source. 

The  internal  genital  organs,  including  ovaries,  uterus  and  vagina  in 
the  female,  and  analogous  structures  in  the  male,  are  derived  from  the 

Miillerian  ducts  and  the  geni- 
tal ridges;  and  although 
these  are  of  mesodermic 
origin,  they  are  developed 
quite  independently  of  that 
portion  of  the  mesoderm 
which  is  being  transformed 
into  the  urinary  bladder,  the 
rectum,  and  the  external  geni- 
talia. The  Miillerian  ducts 
and  genital  ridges  make  their 
appearance  later  than  the  al- 
lantois and  are  united  with  it. 
The  accompanying  draw- 
ings illustrate  the  common 
origin  of  the  urinary  bladder, 
the  rectum  and  the  external 
genitalia,  and  also  show  the  entirely  different  origin  of  the  internal  genital 
organs.  The  union  between  these  groups  of  organs  takes  place  about  the 
fifth  week  of  embryonic  life,  but  there  is  a  marked  difference  throughout 
embryonic  life  in  their  anatomical  and  physiological  development. 

The  bladder,  rectum,  and  external  genitalia  are  rapidly  developed,  so 
that,  at  birth,  the  rectum  and  bladder  have  reached  a  fair  state  of  physio- 
logical competency;  and  the  external  genitalia,  being  developed  from  the 
same  structures,  have  been  carried  along  in  their  evolution  until  they  also 
have  reached  a  considerable  degree  of  development;  the  clitoris  itself  is 
almost  as  large  and  as  sensitive  as  it  becomes  later  in  life.  This,  how- 
ever, is  not  true  of  the  internal  organs  of  generation,  which  at  birth  are 
in  a  very  incomplete  state  of  anatomical  and  physiological  development; 
and  the  rudimentary  condition  of  these  organs,  according  to  Otto  Kiistner,^ 

^"Lehrbuch  der  Gynakologie, "  1904. 


PUCT  Of   mOL4-E'R 

Hir4D    &«/T 


NOrOCHORO 
HCl/KAl,     CANAL 


Fig.  87. — Embryo  of  10  mm.  (About  Five  Weeks). 

Key: Ectodermic  Tissue ; Entodermic  Tissue ; 

....  Mesodermic  Tubes ;  Shading  =  Mesodermic  Tis- 
sue.    (H.  L.  Woodward.) 


ETIOLOGY 


605 


continues  in  the  girl  until  she  is  ten  years  of  age.^  He  says:  "From 
l)irth  until  the  heginning  of  puherty  there  is  no  real  change  in  the  genital 
tract  of  the  girl.  The  uterus  and  vagina  during  this  period  undergo  no 
development." 

The  close  anatomical  and  physiological  relationship  existing  between 
the  bladder,  rectum  and  external  genitalia  of  the  infant  is  still  further 
shown  in  the  nerve  supply  of  these  organs,  which  is  practically  derived 
from  the  same  source,  viz.,  the  third,  fourth  and  fifth  sacral  nerves  and 
the  mesenteric,  sacral,  and  hypogastric  plexuses  of  the  sympathetic.  These 
facts  explain  why  the  external  genital  organs  of  the  infant,  a  few  months 
after  birth,  are  capable  of  responding  to  reflex  excitation  originating  in 
any  of  the  above-named  parts,  and  why  this  excitation  finds  expression  in 
producing  a  miniature  syndrome  so  like  true  masturbation  that  one  must 
conclude  that  this  portion  of  the  infantile  genital  system,  which  is  later 
in  life  to  come  in 
closer  touch  with  the 
fully  developed  inter- 
nal sexual  organs, 
must  even  at  this  ear- 
ly date  in  its  develop- 
ment, have  impressed 
upon  it  the  peculiar 
physiological  function, 
which  makes  it  re- 
spond to  reflex  excita- 
tion by  mimicking  the 
sexual  orgasm. 

Physiological  func- 
tions go  through  vari- 
ous stages  of  evolution 
in  the  embryo,  so  that 
at  birth  most  of  them 
are  developed  to  a  state 

of  physiological  competency;  this  is  not  true,  however,  of  the  functions  of 
the  internal  sexual  and  reproductive  organs,  which,  as  previously  stated,  are 
at  this  time  both  anatomically  and  physiologically  in  a  very  low  state  of  de- 
velopment; so  low,  in  fact,  that  they  are  as  yet  not  endowed  with  physio- 
logical functions.  In  the  infant,  therefore,  while  we  may  have  produced 
by  reflex  excitation  of  the  external  genitalia  a  syndrome  which  mimics 
the  syndrome  of  true  masturbation,  we  cannot  have  the  fully  developed 
orgasm,  or  a  syndrome  that  equals  true  masturbation  in  the  profundity  of 
its  sensations,  or  in  the  injurious  effects  it  produces  on  the  general  nerv- 
ous system. 

In  the  child,  after  ten  years  of  age,  the  internal  sexual  organs  undergo 
rapid  anatomical  and  physiological  development,  and  during  these  years 
of  development  the  intense  feelings  which  accompany  the  sexual  act  may 


NOTOCHORO 


Fio.  88. — Embryo  of  25  mm.  (About  Nine  Weeks.) 


606 


PSEUDOMASTURBATION    IX    INFANTS 


;^^HACHI/S 


_  Pemnant   op 


be  evoked  by  reflex  excitation.  This  is  the  beginning  of  true  masturba- 
tion. I  do  not  mean  to  say,  however,  that  true  masturbation  may  not  oc- 
cur in  certain  children  before  they  are  ten  years  of  age.  Heredity  and 
long-continued  reflex  excitation  may  cause  a  premature  development  of 
the  internal  sexual  organs,  carrying  with  this  development  a  sexual  pre- 
cocity, which  may  make  true  masturbation  a  possibility  in  some  children 
at  a  much  earlier  age.  Pseudomasturbation,  however,  occurs  as  early  as 
the  fourth  month,  and  the  average  age  of  onset  of  this  neurosis,  in  my 
cases,  is  sixteen  months. 

Sex. — The  majority  of  cases  of  true  masturbation  occur  in  male  chil- 
dren, while  of  60  cases  of  pseudomasturbation  55  occurred  in  female  and 
5  in  male  infants. 

Habit. — The  habit  which  is  formed  by  the  practice  of  pseudomasturba- 
tion becomes  after  a  time  one  of  its  most  potent  etiological  factors.     No 

such  sensations  can  be 

produced  by  exciting 
any  other  nervous 
mechanism  in  the 
body.  In  the  first  in- 
stance the  excitation 
may  be  purely  acci- 
dental, or  it  may  have 
been  caused  by  some 
local  irritation ;  but 
after  a  time  the  fre- 
quent excitation  of 
this  nervous  mechan- 
ism makes  it  more  ir- 
ritable and  more  eas- 
ily excited,  so  that 
very  slight  reflex  ex- 
citation is  capable  of 
producing  a  paroxysm  of  pseudomasturbation. 

In  the  older  child,  environment  may  act  as  an  etiological  factor  by 
throwing  children  together,  offering  the  opportunity  for  imitation.  It 
may  also  act  by  surrounding  the  child  with  an  atmosphere  of  immorality 
and  vice,  which  offers  no  restraining  influence  upon  the  development  of 
this  habit.  In  the  infant,  environment  may  predispose  by  producing  bad 
hygienic  surroundings,  which  may  mean  uncleanliness  and  lack  of  care 
of  the  genital  organs,  with  increased  local  excitation,  or  it  may  mean  mal- 
nutrition and  other  causes  of  general  nervous  irritability.  The  fact  should 
also  be  noted  that  unscrupulous  nurses  sometimes  teach  infants  the  habit 
of  pseudomasturbation  as  a  means  of  quieting  their  fretfulness. 

In  fully  three-fourths  of  the  cases  there  is  a  distinct  neurotic  in- 
heritance; in  infants  suffering  from  hereditary  neuroses  the  reflex  causes 
of  pseudomasturbation  may  be  very  slight;  so  slight,  in  fact,  as  to  escape 


Fig.  89. — Child  at  Birth. 


TREATMENT  607 

observation.  A  goiity  inheritance  may  also  predispose  to  this  condition  by 
producing  in  infants  a  tendency  to  periodic  attacks  of  acid  urine.  I  have 
had  under  observation  a  number  of  such  cases  where  there  was  a  return 
of  the  pseudomasturbation  with  every  return  of  the  attacks  of  acid  urine, 
from  which  these  infants  suffered. 

Malnutrition  in  infants  suffering  from  pseudomasturbation  influences 
very  much  the  severity  and  frequency  of  the  attacks.  An  attack  of  en- 
teritis, influenza,  or  any  other  acute  disease,  which  causes  a  rapid  de- 
terioration in  general  health,  will  produce  a  return  of  the  habit,  which  can 
again  be  relieved  only  by  complete  convalescence  from  the  intercurrent 
disease. 

Direct  Causes. — Irritation  of  the  nervous  mechanism  which  controls 
the  sexual  organs  is  the  all-important  exciting  factor  in  the  development 
of  pseudomasturbation  in  infancy.  The  site  of  this  irritation  in  the  vast 
majority  of  cases  is  in  the  genitourinary  organs,  the  rectum  or  the  lower 
portion  of  the  large  intestine. 

Progfnosis. — This  is  good.  I  am  convinced  that  pseudomasturbation 
occurring  in  infants  under  two  years  of  age  will  almost  always  get  well 
under  proper  treatment.  The  tendency  in  this  disease  is  to  spontaneous 
recovery,  and  the  average  length  of  time  required  to  bring  about  this  re- 
sult is  about  nineteen  months.  The  disease  is  a  habit  neurosis,  and  time, 
with  a  normal  development  of  the  nervous  system  which  tends  to  stability 
and  greater  inhibitory  control,  is  the  most  important  factor  in  the  cure 
of  the  worst  cases.  There  is  almost  no  connection  between  pseudomas- 
turbation in  infancy  and  true  masturbation  in  later  life.  It  is  possible, 
however,  that  a  badly  neglected  case  of  pseudomasturbation  occurring  in  a 
strongly  neurotic  infant  may  continue  until  it  becomes  one  of  true  mas- 
turbation in  the  child. 

There  is,  I  believe,  no  relationship  between  pseudomasturbation  and 
epilepsy.  The  two  conditions  may  coexist,  and  one  can  understand  that 
the  neurotic  conditions  which  produce  or  underlie  epilepsy  may  predispose 
to  pseudomasturbation,  but  surely  pseudomasturbation  as  here  differentiated 
from  true  masturbation  cannot  be  classed  among  the  causes  of  epilepsy. 

Treatment. — In  the  treatment  of  pseudomasturbation,  as  in  the  treat- 
ment of  all  habit  neuroses,  it  is  imperative  that  the  habit  be  interrupted 
as  soon  as  possible.  The  importance  of  this  cannot  be  overestimated.  The 
habit,  whatever  may  have  been  its  original  exciting  causes,  has  been  en- 
grafted upon  the  nervous  system,  and  an  interruption  breaks  into  and 
helps  destroy  the  habit,  and  in  this  way  makes  for  the  permanent  cure  of 
the  affection.  The  accomplishment  of  this  purpose,  in  some  eases,  is  a 
matter  of  great  difficulty.  In  the  vast  majority  of  cases,  however,  it  is  a 
comparatively  easy  matter. 

As  this  act  is  performed,  as  a  mle,  while  the  infant  is  lying  down, 

and  commonly  when  it  awakens  from  sleep,  and  when  the  parts  are  more 

or  less  irritated  by  the  soiled  diaper,  it  is  imperative  that  a  careful  nurse, 

by  constant  watching,  shall  be  present  to  forcibly  prevent  the  act  by  tak- 

40 


608  PSEUDOMASTURBATION    IN    INFANTS 

jng  the  child  up,  changing  the  diaper,  cleansing  the  parts,  and  dusting 
them  witli  a  soothing  powder.  Tlie  watchfulness  of  the  nurse  should  con- 
tinue throughout  the  waking  hours  of  the  child,  so  as  to  keep  the  parts 
always  clean,  dry,  and  free  from  irritating  discharges.  The  child  should 
he  kept  in  a  sitting  posture  as  much  of  the  time  as  possible,  and  even  when 
taken  for  an  outing  should,  if  old  enough,  be  carried  about  in  a  go-cart 
in  preference  to  the  ordinary  baby  carriage;  the  object  of  this  is  to  keep 
the  child  in  the  position  which  least  tempts  it  to  practice  the  act,  and  the 
nurse  should  be  directed  to  forcibly  interfere  at  all  times  to  prevent  its 
accomplishment. 

In  children  over  two  years  of  age  mild  punishment  is  sometimes  very 
effective,  and  the  child,  when  old  enough,  should  be  given  to  understand 
that  it  will  be  rewarded  if  it  abstains  from  the  habit.  Moral  suasion 
should  be  practiced  with  older  children.  It  is  evident  that  the  above  treat- 
ment can  only  successfully  be  carried  out  by  an  ever-watchful,  patient, 
judicious  nurse. 

In  the  more  severe  cases  forcible  restraint  during  sleep  may  be  neces- 
sary, as  the  infant  cannot  be  watched  constantly  during  the  long  hours  of 
the  night,  and  it  may  on  waking  practice  this  habit.  Forcible  restraint 
may  be  practiced  in  many  ways.  No  special  device  is  suitable  to  all  cases. 
But  if  the  physician  is  sufficiently  impressed  with  the  necessity  for  this 
method  of  treatment,  the  particular  mechanical  device  by  which  the  end 
is  to  be  accomplished  may  be  left  to  his  ingenuity.  If  the  infant  sleeps  in 
pajamas  the  heels  of  this  garment  may  be  fastened  by  safety  pins  to  the 
mattress  in  such  a  manner  as  to  hold  the  legs  apart,  and  prevent  the 
flexion  of  the  thighs;  at  the  same  time  the  child's  body  is  prevented  from 
slipping  down  in  the  bed  by  a  ribbon  stretched  from  the  back  of  the 
pajamas  to  the  head  of  the  bed.  In  younger  children  a  large  diaper  may 
be  folded,  as  suggested  by  Kerley,  so  as  to  prevent  the  thighs  being  approxi- 
mated. Many  writers  have  recommended  heavy  mechanical  devices  re- 
sembling fracture  frames,  into  which  the  child  is  tied  when  it  is  put  to 
bed.  The  profound  sleep  of  the  young  child  lends  itself  to  this  mode  of 
treatment,  and  the  patient  quickly  becomes  accustomed  even  to  such 
cumbersome  appliances  as  double  thigh  splints  with  a  separating  foot- 
board. It  must  indeed,  however,  be  a  very  severe  case  to  justify  this  form 
of  apparatus. 

When  one  has  settled  upon  a  plan  for  interrupting  the  habit,  he  should 
next  turn  his  attention  to  the  removal  of  all  local  reflex  causes  of  irrita- 
tion. In  the  male  infant,  phimosis  and  preputial  adhesions  should  be 
treated,  and  in  the  female  infant  the  preputial  hood  should  be  separated 
from  the  clitoris;  vulvovaginitis  and  all  irritations  of  the  vaginal  orifice 
should  be  treated.  Pinworms,  diseases  of  the  rectum,  local  eczema,  and, 
in  fact,  all  abnormalities  of  the  rectum  and  genitourinary  organs  should 
be  removed,  and  the  child's  clothing  should  be  carefully  arranged  so  as 
not  to  produce  local  irritation. 

Too  much  stress  cannot  be  laid  upon  the  importance  of  removing  all 


TREATMENT  609 

possible  sources  of  local  irritation  of  the  nervous  mechanism  which  con- 
trols the  genital  organs,  as  the  reflex  factor  is  not  uncommonly  the  most 
important,  not  only  in  starting,  but  continuing,  the  habit  of  pseudomas- 
turbation. 

I  wish,  however,  to  call  special  attention  to  increased  acidity  of  the 
urine  as  a  potent  reflex  factor  in  many  of  these  cases;  I  believe  it  is  the 
most  important  of  all  reflex  factors;  it  was  present  in  one-third  of  my 
cases.  This  condition  may  be  treated  by  benzoate  of  soda  and  tincture  of 
belladonna  put  up  in  some  palatable  non-irritating  vehicle.  The  alkali 
and  the  belladonna,  the  latter  in  small  doses,  should  be  given  over  a  long 
period  of  time  when  there  is  any  tendency  to  continuous  or  periodic  acidity 
of  the  urine. 

General  Treatment. — Many  cases,  especially  those  over  two  years  of 
age,  are  benefited  by  bromid  of  potash  and  belladonna  given  at  bedtime. 
This  treatment  is  especially  applicable  in  those  eases  where  the  habit  is 
practiced  during  the  night. 

An  atmosphere  of  quiet  and  rest  must,  if  possible,  at  all  times  surround 
the  child.  The  importance  of  this  injunction  is  as  great  in  this  as  in  the 
treatment  of  any  other  neurosis. 

By  the  treatment  above  outlined  it  is  possible  in  practically  every  case 
to  control  the  habit,  but  it  must  be  remembered  that  this  treatment  must, 
with  more  or  less  rigor,  depending  upon  the  severity  of  the  case,  be  kept 
up  not  only  for  months,  but  sometimes  for  two,  three,  or  even  four  years. 
Where  the  treatment,  however,  is  carefully  Ipoked  after  one  may  count 
upon  a  permanent  cure  in  the  great  majority  of  cases  within  one  or  two 
years.  In  those  that  are  less  carefully  looked  after  four  or  five  years  may 
be  necessary  to  accomplish  a  cure.  One  must  recognize,  therefore,  that 
when  the  above  treatment  has  been  put  into  operation,  and  the  habit  con- 
trolled, the  patient  has  been  placed  under  conditions  where  time,  by 
strengthening  the  stability  and  inhibitory  control  of  the  nervous  system, 
will  accomplish  a  cure.  It,  therefore,  becomes  important  at  this  stage  of 
the  treatment  to  guard  carefully  the  child's  general  nutrition,  treating  any 
special  form  of  malnutrition  that  may  exist,  and  securing  normal  de- 
velopment by  careful  diet  and  proper  hygienic  measures,  including  an  out- 
door life.  Cod-liver  oil,  iron,  arsenic  and  other  tonics  may  enter  into  the 
treatment.  It  is  important  that  the  child  should  be  guarded  against  con- 
stipation and  all  gastrointestinal  disturbances,  as  attacks  of  this  kind  al- 
most alwavs  cause  a  recurrence  of  the  habit  in  an  apparently  convalescent 
child.  The  daily  bath,  followed  by  a  cold  douche,  has  been  used,  with 
success. 


SECTION  XI 

DISEASES  OF  THE  NERVOUS  SYSTEM 

CHAPTER    LXXVIII 

DISEASES    OF    THE    BEAIN 

INFANTILE    CEREBRAL    PALSIES 

Infantile  cerebral  palsies  comprehend  a  group  of  palsies  which,  in  their 
general  clinical  manifestations,  are  so  similar  that  they  are  classed  to- 
gether. They  are  characterized  by  spastic  paralysis  and  by  various  other 
disturbances  of  cerebral  functions  associated  with  a  great  variety  of  cere- 
bral lesions.  That  symptoms  so  like  in  character  can  be  produced  by 
pathological  lesions  so  unlike  in  character  and  affecting  such  different 
parts  of  the  brain  is  due  to  the  fact  that  these  lesions,  occurring  so  early 
in  the  life  of  the  child,  seriously  interfere  with  the  general  functional 
development  of  the  brain.  These  cases  may  be  symptomatically  grouped 
as  hemiplegia,  paraplegia  and  diplegia. 

Etiology. — The  lesions  which  produce  spastic  paraplegia  and  spastic 
diplegia  almost  always  occur  at  or  before  birth,  although  the  symptoms 
may  not  appear  for  months  later,  but  they  never  make  their  appearance 
after  the  third  year.  The  lesions  which  produce  spastic  hemiplegia  may 
occur  at  or  before  birth,  but  they  usually  occur  after  birth.  The  symp- 
toms of  these  postnatal  palsies,  as  a  rule,  follow  quickly  the  injury  to 
the  brain;  in  some  instances,  however,  the  palsies,  if  slight,  may  not  be 
discovered  for  months  or  years  later. 

Prenatal  palsies  are  due  to  traumatism,  such  as  may  result  from 
a  blow  or  a  fall,  or  to  uremic  convulsions  or  exhausting  illness  during 
pregnancy,  and  hereditary  defects  transmitted  by  neurotic  or  alcoholic 
parents.  These  exciting  causes  may  produce  cortical  hemorrhage,  throm- 
bosis, porencephalia,  agenesis  corticalis,  and  degeneration  of  the  fibers  of 
the  pyramidal  and  lateral  tracts.  The  lesions  produced  are  usually  ex- 
tensive and  result  in  diplegia  or  paraplegia. 

Natal  palsies  are  due  to  asphyxia,  false  position  of  the  head  in  utero, 
and  traumatism  from  protracted  labor  and  the  improper  use  of  forceps. 
There  is  no  doubt,  however,  that  the  skillful  use  of  obstetrical  forceps  has 
saved  many  children  from  serious  brain  injury  at  birth ;  this  is  especially 
true  in  those  cases  in  which  there  is  a  premature  discharge  of  liquor 
amnii.  The  lesion  is  due  usually  to  meningeal  hemorrhage  producing 
subsequent  lesions  of  the  cortical  motor  area ;  more  rarely  the  hemorrhage 
is  directly  into  the  brain  substance  and  is  followed  by  lack  of  functional 

610 


INFANTILE    CEREBRAL   PALSIES  611 

development  and  by  inflammatory  and  degenerative  changes  on  the  part 
of  the  brain.  These  cases  occur  much  more  commonly  in  the  first-born,  and 
the  paralysis  which  follows  is  commonly  diplegic  and  paraplegic,  but  it 
may  be  hemiplegic. 

Postnatal  palsies  are  due  to  head  injuries  from  blows  and  falls,  to 
violent  and  protracted  general  convulsions,  whatever  may  be  their  cause,  to 
severe  paroxysms  of  whooping-cough  with  the  cerebral  congestion  which 
they  produce,  and  to  hereditary  syphilis,  meningitis,  measles,  influenza, 
and  other  contagious  diseases.  The  lesions  produced  are  cerebral  hemor- 
rhage, usually  cortical,  rarely  intracerebral,  thrombosis,  embolism  and 
hydrocephalus. 

Pathology. — The  primary  lesion  is  usually  meningeal  hemorrhage, 
which  may  occur  over  any  portion  of  the  cortex.  In  diplegia  and  para- 
plegia it  is  bilateral,  in  hemiplegia  it  is  unilateral,  find  is  commonly 
located  over  the  upper  lateral  surface  of  the  brain,  involving  the  motor 
areas  in  front  of  the  fissure  of  Rolando.  More  rarely  the  initial  lesion 
is  an  intracranial  hemorrhage,  a  thrombus,  an  embolus  or  a  chronic  menin- 
gitis, producing  hydrocephalus.  Whatever  may  be  the  original  cause,  a 
meningoencephalitis  occurs  at  the  point  of  injury,  producing  softening, 
fatty  degeneration  and  atrophy  of  cortical  brain  substance.  Secondary 
sclerosis  and  scar  tissue  are  in  time  left  to  mark  the  site  of  the  original 
injury,  and  secondary  degenerations  may  occur  in  the  posterior  and 
lateral  columns  of  the  cord.  Porencephalia  is  very  commonly  found,  es- 
pecially in  the  prenatal  cases;  in  this  condition  a  cyst  replaces  a  large 
portion  of  the  brain  substance.  As  a  result  of  these  lesions  the  func- 
tional development  of  the  brain  is  retarded  and  epilepsy  and  imbecility  may 
result. 

The  following  table  from  Sachs,  to  whose  careful  studies  we  owe 
much  of  our  knowledge  of  this  disease,  gives  us  an  excellent  classifica- 
tion of  these  cases  from  the  standpoint  of  the  age  incident: 

CLASSIFICATION  OF  INFANTILE  CEREBEAL  PALSIES    (SACHS). 


Groups. 


I.  Paralyses  of  intra- 
uterine  onset. 

II.  Birth  palsies. 


III.     Acute  (acquired) 
palsies. 


MoBBiD  Lesion. 


Large  cerebral  defects.  (Porencephaly.)  Defective  devel- 
opment of  pyramidal  tracts.  Agenesis  corticalis.  (Highest 
nerve  elements  involved.) 

Meningeal  hemorrhage,  rarely  intracerebral  hemorrhage. 
Later  conditions:  Meningoencephalitis  chronica,  sclerosis, 
and  cysts;  partial  atrophies. 

Hemorrhage  (meningeal,  and  rarely  intracerebral) ;  throm- 
bosis   (from   syphilitic  endarteritis  and  in  marantic  condi- 
tions);  embolism.     Later    conditions:  Atrophy,    cysts,    and 
sclerosis   (diffuse  and  lobar). 
Meningitis  chronica. 
Hydrocephalus  (seldom  the  sole  cause). 
Primary  encephalitis;    polioencephalitis   acuta    (Striimpell). 


612 


DISEASES    OF    THE   BKAIN 


Symptomatology. — Hemiplegia. — This  is  the  most  frequent  form  of 
infantile  cerebral  palsy.  It  may  be  due  to  brain  lesions  occurring  at  birth 
or  in  early  childhood,  and  the  symptoms  which  announce  the  onset  of  the 
paralyses  differ  greatly  in  the  natal  and  postnatal  varieties. 

When  the  injury  to  the  brain  occurs  after  birth,  the  most  common 
period  of  incidence  is  from  the  sixth  to  the  eighteenth  month.  The  onset 
is  almost  always  announced  by  severe  general  convulsions,  which  may  be 
repeated  at  intervals  over  a  number  of  days,  and  in  the  more  severe  cases 

an  intervening  coma  occurs.  High  fever  and 
vomiting  usually  accompany  the  initial  convul- 
sion, and  they  may  persist  throughout  the  con- 
vulsive period.  It  is  now  the  generally  ac- 
cepted opinion  that  in  some  instances  the  acute 
brain  lesions  may  be  the  direct  cause  of  the 
convulsion,  fever  and  vomiting.  In  other  in- 
stances a  severe  convulsion  from  toxemia, 
whooping-cough  or  other  causes  may  produce 
the  cerebral  hemorrhage,  which  in  turn  may 
directly  aggravate  the  convulsion  and  other 
symptoms.  In  either  event  the  onset  is  the 
same,  and  these  symptoms  are  quickly  followed 
by  the  characteristic  paralysis.  The  more  vio- 
lent the  onset  the  more  marked  will  be  the  sub- 
sequent paralysis. 

When  the  injury  to  the  brain  occurs  at 
birth  this  fact  may  be  announced  by  cyanosis 
and  convulsions  during  the  first  days  of  life. 
Following  this  acute  cortical  irritation  the 
nervous  symptoms  may  subside  and  the  subse- 
quent symptoms  of  the  brain  injury  may  await 
the  development  of  the  pyramidal  tracts  and 
the  functional  development  of  cortical  and  other 
brain  centers.  With  the  development  of  the 
myelin  sheaths  of  the  fibers  of  the  pyramidal 
tracts  during  the  first  few  months  of  life,  the 
brain  of  the  infant  is  put  in  closer  communi- 
cation with  the  spinal  cord,  and,  as  a  result, 
there  may  slowly  develop  after  the  third  or  fourth  month  a  spastic  hemiple- 
gia, or  a  more  extensive  paralysis,  and  late  convulsive  disorders  may 
also  occur.  In  some  of  these  cases  the  primary  injury  to  the  brain 
may  escape  notice,  and  later  an  insidious  spastic  paralysis  may  de- 
velop, and  the  subsequent  history  may  be  very  like  those  postnatal 
cases  which  are  ushered  in  with  violent  convulsions,  to  be  followed 
at  once  by  a  well-marked  paralysis,  except  that  in  these  latter  cases  the 
symptoms  due  to  agenesis  of  the  higher  nerve  centers  are  not  usually  so 
pronounced.     These  early  symptoms  in  both  natal  and  postnatal  cases. 


FiQ.  90. — Hemiplegia  From 
Cerebral  Hemorrhage. 
(Sachs.) 


INFANTILE    CEREBRAL    PALSIES  613 

whatever  may  be  the  character  of  their  onset,  are  followed  by  a  spastic 
hemiplegia,  which  may  involve  the  face,  arm  and  leg  of  one  side  of  the 
body.  It  is  usually  more  marked  in  the  arm.  The  amount  of  incapacity 
in  the  paralyzed  side  will  vary  with  the  extent  of  the  brain  lesion.  In 
mild  cases  it  may  come  on  after  school  age,  and  may  be  only  a  slight 
muscular  weakness  developed  by  exercise.  In  severe  cases  it  may  be  so 
great  as  to  render  the  arm  and  leg  useless. 

Muscular  contractures  are  the  characteristic  symptoms  that  differentiate 
this  from  the  flaccid  paralyses;  the  joints  are  bent  and  held  more  or  less 
rigid;  the  forearm  is  pronated  and  flexed  on  the  adducted  arm,  the  wrist 
is  drawn  downward  and  inward,  the  hand  is  clenched,  the  fingers  strongly 
flexed  toward  the  palm,  the  knee  bent,  the  foot  extended  downward  and 
rotated  inward,  and  the  toes  contracted.  More  or  less  recovery  takes  place 
in  the  paralyzed  parts,  especially  in  the  leg,  and  as  the  patient  regains  the 
power  of  walking  he  has  a  spastic  gait,  dragging  his  toes  and  swinging  his 
leg.  In  some  instances  fairly  good  control  of  the  log  is  finally  obtained, 
leaving  only  a  slight  muscular  weakness.  But  the  contractures  of  the  arm 
are  more  permanent.  In  a  large  percentage  of  the  cases  there  develop  in 
the  paralyzed  limb  rhythmic  tremor,  choreiform  movements,  athetosis,  or 
associated  movements.  In  the  latter  condition  the  paralyzed  arm  imi- 
tates the  movements  of  the  good  one. 

All  of  the  reflexes  in  the  paralyzed  extremities  are  greatly  exaggerated, 
the  kneejerk  being  especially  valuable  as  a  diagnostic  sign,  a  slight  tap 
upon  the  tendon  producing  a  maximum  contraction.  The  Babinski  and 
allied  signs  are  usually  present.  There  is  more  or  less  lack  of  develop- 
ment in  the  paralyzed  parts  as  time  goes  on,  which  results  in  shortening 
and  shrinking  of  the  limb  without  muscular  atrophy.  All  of  the  paralyzed 
muscles  respond  in  a  normal  manner  to  electrical  excitation.  Motor  aphasia 
is  usually  associated  with  right  hemiplegia,  but  if  the  lesion  occurs  be- 
fore the  child  has  commenced  to  talk,  then  speech  is  late  in  development. 
As  Sachs  has  noted,  however,  aphasia  in  the  young  child  may  also  be 
associated  with  left-sided  hemiplegia.  In  course  of  time  the  child,  as  a 
rule,  slowly  regains  or  develops  the  faculty  of  speech. 

Epilepsi/  occurs  in  from  30  to  50  per  cent,  of  these  cases.  It  may 
begin  within  a  few  weeks  after  the  onset  of  the  paralysis,  or  it  may  not 
appear  for  years.  Sachs'  valuable  studies  have  thrown  much  light  on  the 
relation  of  epilepsy  to  early  spastic  palsies  which  have  disappeared,  or 
which  were  perhaps  so  slight  at  the  time  as  to  almost  escape  unnoticed, 
and  his  advice  to  carefully  investigate  every  case  of  epilepsy  with  refer- 
ence to  its  possible  origin  in  an  early  cerebral  hemorrhage  will  ofttimes 
reveal  the  cause  of  what  would  otherwise  be  considered  as  cases  of  idio- 
pathic epilepsy  of  obscure  origin.  Exaggerated  reflexes  and  weak  muscular 
action  on  one  side  of  the  body,  when  associated  with  epilepsy,  are  strongly 
suggestive  of  an  early  cerebral  lesion.  The  epilepsy  may  be  of  either  the 
grand  mal  or  petit  mal  type. 

Feeblemindedness  is  one  of  the  most  frequent  and  distressing  symp- 


614 


DISEASES    OF   THE   BEAIN" 


toms  of  this  disease.  Complete  imbecility  or  slight  mental  weakness  may 
result,  and  between  these  two  extremes  we  may  have  every  grade  of  mental 
defect.  The  most  complete  imbecility  is  usually  found  in  the  cases  of 
diplegia  and  paraplegia.  The  hemiplegic  cases  may  apparently  retain 
their  normal  mental  power,  but,  as  a  rule,  they  are  not  able  to  keep  pace 
mentally  with  normal  children  in  the  severe  strain  that  comes  with  ad- 
vanced school  work.  The  mental  improvement  in  these  cases  should  occur 
early,  if  it  is  to  occur  at  all,  and  it  is  futile  to  hope  for  further  intellectual 

development  in  children  eight  or  nine 
years  of  age  who  have  been  in  a  state 
of  comparative  imbecility  for  years. 
Deaf  mutism,  blindness  and  hemianop- 
sia may  occur. 

Diplegia. — This  is  a  double  hemi- 
plegia, both  arms  and  both  legs  being 
affected.  It  is  perhaps  the  most  com- 
mon form  of  cerebral  paralysis  during 
the  first  six  months  of  life.  It  is  pro- 
duced by  natal  or  prenatal  injuries,  and 
is  an  extensive  double  brain  lesion, 
which  may  be  marked  by  convulsive 
seizures  during  the  first  days  of  life. 
The  paralysis,  however,  may  not  occur 
for  weeks  or  months  later,  but  never 
develops  after  the  third  year.  In  this 
condition  the  mental  defects  are  much 
more  pronounced  than  in  hemiplegia. 
Imbecility  is  the  rule,  and  with  this 
hopeless  lack  of  mental  development 
there  is  a  marked  lack  of  physical  de- 
velopment. Many  of  these  cases  never 
gain  sufficient  control  of  their  legs  to 
walk.  Others  learn  to  walk  with  a  spas- 
tic crosslegged  gait  between  the  sixth 
and  the  ninth  year  of  life.  Epilepsy 
develops  in  perhaps  50  per  cent,  of  these 
cases.  Except,  however,  for  the  extent  of  the  paralysis  and  the  increased 
severity  of  all  the  symptoms,  this  form  of  the  disease  runs  a  course  similar 
to  spastic  hemiplegia  just  described. 

Paraplegia. — Paraplegia  is  also  a  double  spastic  paralysis  involving 
both  legs,  produced  by  a  double  natal  or  prenatal  injury  to  the  brain  in- 
volving both  leg  centers.  The  lesion  is,  therefore,  more  circumscribed  than 
in  diplegia.  Except  for  the  fact  that  the  paralysis  is  confined  to  the  legs, 
its  clinical  history  is  very  like  that  of  cerebral  diplegia. 

Monoplegia. — Monoplegia  is  very  rare.  Most  of  the  cases  which  at 
first  glance  present  this  form  of  paralysis  are  old  cases  of  hemiplegia,  in 


Fig.  91. — Spastic      Diplegia      from 
Cerebral  Hemorrhage.  (Sachs.) 


INFAJ^TTtLE    CEREBKAL    PALSIES  G15 

which  the  leg  has  apparently  recovered,  leaving  the  arm  contractured  and 
paralyzed.  A  closer  examination  of  these  cases  will  often  show  a  weakness 
of  the  muscles  of  the  leg  and  exaggerated  reflexes,  which  are  indications 
of  the  earlier  paralysis  of  that  part. 

Prognosis. — In  diplegia  and  paraplegia  the  prognosis  is  invariably  bad. 
Fortunately  many  of  the  most  severe  cases  die  in  infancy;  the  others 
remain  more  or  less  hopeless  invalids,  incapable  of  mental  or  physicdl 
development.  The  prognosis  in  hemiplegia,  while  not  good,  is  much  bet- 
ter, especially  in  those  cases  produced  by  lesions  occurring  after  birth. 
Many  of  these  postnatal  hemiplegias  recover  with  little  or  no  mental  de- 
fect, but  more  or  less  spastic  paralysis  of  the  forearm  and  hand  remains  in 
a  great  majority  of  the  cases;  but  there  is  always  a  possibility  that  epilepsy 
may  develop  between  the  sixth  and  fifteenth  year.  The  prognosis  in  hemi- 
plegic  cases  dating  from  birth  is  not  so  good ;  in  these  the  residual  paraly- 
sis and  the  mental  deficiency  are  more  marked. 

Diagnosis. — The  differential  diagnosis  of  cerebral  palsies  from  the 
other  paralyses  of  childhood  has  been  considered  under  Infantile  Paralysis. 
Treatment. — In  diplegia  and  paraplegia  the  underlying  pathological 
lesions  cannot  be  influenced  by  medical  or  surgical  measures.  It  therefore 
becomes  the  duty  of  the  physician  to  prolong  the  lives,  modify  the  suffer- 
ings and  control  the  nervous  symptoms  of  these  unfortunate  children,  many 
of  whom  live  for  years  in  a  hopeless  state  of  imbecility  with  fond  mothers 
giving  up  their  whole  lives  to  care  and  nursing.  The  dietetic  treatment 
is  most  important,  since  a  slight  constipation,  intestinal  fermentation,  or 
a  mild  degree  of  intestinal  toxemia  may  greatly  aggravate  the  nervous 
symptoms,  producing  intense  irritability,  sleeplessness  and  even  convul- 
sions. The  comfort  of  these  patients  depends  largely  upon  the  ability 
of  the  physician  to  keep  the  gastrointestinal  canal  in  normal  condition, 
and  yet  so  feed  them  that  they  will  be  properly  nourished.  The  sedative 
treatment  is  also  important;  sleeplessness,  nervous  irritability,  muscular 
twitchings  and  convulsive  disorders  may  require  the  use  of  bromids  over  a 
long  period  of  time. 

The  hemiplegic  cases  offer  a  much  more  hopeful  field  for  treatment. 
The  convulsions  and  fever  which  mark  their  onset  are  to  be  treated  with 
baths,  ice-caps  to  the  head,  and  the  rectal  or  oral  administration  of  chloral 
and  bromids  as  directed  under  Convulsions.  The  subsequent  treatment 
of  these  cases  has  in  view  the  improvement  of  the  general  health  of  the 
child,  the  development  of  the  paralyzed  part,  and  the  prevention  of  con- 
tractures. Good  food,  outdoor  life,  systematic  massage  and  passive  exercise 
to  overcome  contractures  are  the  most  important  agents  we  have  in  ac- 
complishing these  ends ;  the  massage  should  be  general  and  should  be  given 
every  other  day  for  months  or  even  years  if  necessary.  Passive  movements 
should  be  resorted  to  three  or  four  times  every  day ;  these  should  be  gentle 
and  should  be  directed  to  overcoming  the  contractures;  the  contractured 
hand,  forearm  and  leg  should  be  gently  extended  five  or  six  times  at  each 
sitting.     The  orthopedic  treatment  is  also  most  important  and  should  be 


616  DISExVSES    OF    THE    BRAIN 

directed  by  an  orthopedic  surgeon.  Properly  applied  braces,  or  the  length- 
ening of  and  transplantation  of  contractured  tendons,  may  put  the  child 
upon  his  feet,  or  give  him  better  use  of  his  arm,  thus  enabling  him  to 
expedite  his  recovery  by  active  exercise.  It  is  most  important  that  children 
who  are  apparently  approaching  the  normal  in  mental  and  physical  de- 
velopment should  not  be  pushed  either  mentally  or  physically.  These 
apparently  convalescent  children  should  be  carefully  guarded  over  a  num- 
ber of  years  until  it  is  plain  that  mental  training  will  not  injure  them. 
M'any  of  these  children  under  the  strain  of  school  work  become  very 
neurotic,  and,  in  some  instances,  they  develop  epilepsy. 

BRAIN  TUMORS 

The  nature  and  position  of  brain  tumors  in  children  are  shown  in  the 
following  tables  from  Starr: 

Nature  op  Tumok.  Position. 

Tuberculous  tumors    152      Cerebellum    96 

Glioma 37       Pons  varolii   38 

Sarcoma    34       Centrum  ovale   35 

Gliosarcoma    5       Basal  ganglia  and  lateral  ventricles.  .   27 

Cystic    30      Cerebral  cortex   21 

Gummata     2       Corpora      quadrigemina      and      crura 

Other  varieties 30  cerebri  21 

Base 8 

Fourth  ventricle    5 

Medulla  6 

Multiple  tumors 43 

Symptomatology. — The  onset  is  insidious.  The  general  symptoms 
develop  slowly,  may  for  a  time  come  and  go,  and  then  gradually  become 
permanent. 

Headache  gradually  develops,  but  in  time  it  becomes  very  intense,  re- 
curring in  agonizing  paroxysms,  and  in  the  interval  between  these  severe 
attacks  the  pain  may  be  dull  and  boring  in  character.  Headache  is  one  of 
the  most  significant  symptoms,  as  it  occurs  early,  is  present  in  nearly 
every  case,  and  increases  in  intensity  as  the  tumor  enlarges.  It  is  of 
especial  value  in  children,  since  headaches  of  this  character  from  other 
causes  are  extremely  rare  at  this  age.  Vomiting  usually  accompanies  the 
headache.  It  may  or  may  not  be  associated  with  nausea,  is  projectile  in 
character,  recurs  without  apparent  cause,  and  is  not  in  any  way  associated 
with  the  taking  of  food.  Vertigo  is  associated  with  the  headache  and 
vomiting.  The  dizziness  may  be  slight  or  extreme.  If  the  patient  is  on 
his  feet  he  may  stagger  and  fall  to  the  floor.  Vertigo  may  be  brought  on 
in  these  cases  by  changing  the  position  of  the  head.  It  is  more  frequent 
and  more  pronounced  when  the  tumor  is  located  in  the  cerebellum  or  in 
the  pons.  General  or  localized  convulsions  of  every  grade  of  severity  may 
occur.    In  some  cases  they  are  absent  altogether.    They  are  more  common 


ABSCESS    OF    THE    BEAIN  617 

and  more  violent  when  the  motor  areas  of  the  cortex  are  involved,  and 
their  diagnostic  value  depends  largely  upon  their  association  with  the 
other  symptoms  above  noted. 

Optic  Neuritis. — The  occurrence  of  the  above  symptoms  should  sug- 
gest an  examination  of  the  eyes  and,  if  brain  tumor  exists,  a  double  optic 
neuritis  will  commonly  be  found.  It  occurs  in  80  to  85  per  cent,  of  ad- 
vanced cases,  and  is  slightly  more  common  in  cerebellar  tumofs.  Optic 
neuritis  is,  therefore,  when  taken  in  connection  with  the  above  symptom 
group,  the  most  distinctive  sign  we  have  of  brain  tumor.  It  may  be  asso- 
ciated with  partial  or  complete  loss  of  sight  and  hearing;  this  combina- 
tion of  symptoms  should  suggest  cerebellar  tumor.  As  the  disease  pro- 
gresses the  intellect  suffers,  the  child  becomes  dull,  and  may  have  but 
feeble  mental  capacity.  Convulsions,  stupor,  coma  and  unconsciousness 
occur  before  death. 

Localizing  Symptoms. — To  the  above  symptom  group  are  added  the 
symptoms  which  result  from  a  disturbance  of  brain  functions,  which  vary 
with  the  location  of  the  tumor.  These  localizing  symptoms,  however,  are 
the  same  in  the  child  as  they  are  in  the  adult,  and  do  not,  therefore,  demand 
consideration  here. 

Diagnosis. — Tumors  should  not  be  confused  with  abscess  of  the  brain; 
the  latter  is  an  acute  febrile  process  characterized  by  chills  and  fever  and 
associated  with  some  septic  process,  which  can  usually  be  located.  It 
should  also  be  remembered  that  brain  tumors  are  commonly  tuberculous, 
and  other  evidences  of  this  disease  usually  precede  the  development  of  the 
brain  tumors.  An  examination  of  the  cerebrospinal  fluid  should  always 
be  made,  as  it  may  help  to  exclude  the  various  forms  of  meningitis. 

Treatment. — The  only  cases  that  are  at  all  influenced  by  medical  treat- 
ment are  those  due  to  syphilis,  and,  although  these  are  rare,  it  is  perhaps 
advisable  to  give  every  case  the  benefit  of  antisyphilitic  treatment.  If 
the  symptoms  are  not  improved  by  a  course  of  mercury  and  iodid  of 
potash,  then  the  only  hope  lies  in  surgical  intervention.  In  most  cases  it 
is  necessary  to  trephine  and  make  an  exploratory  investigation  before  the 
advisability  of  a  radical  surgical  operation  can  be  determined  upon.  A 
small  percentage  of  these  cases  are  improved  or  cured  by  the  removal  of 
the  tumor. 

ABSCESS  OF  THE  BRAIN 

Abscess  of  the  brain  is  a  rare  disease.  In  childhood  it  is  usually 
secondary  to  chronic  otitis  media  or  mastoiditis,  but  may  also  result  from 
fractures  of  the  skull,  septic  processes  in  the  frontal  and  ethmoid  sinuses, 
and  more  rarely  from  septic  foci  in  remote  parts  of  the  body.  Abscesses 
are  most  commonly  located  in  the  temper osphenoidal  lobes,  the  frontal 
lobes  and  the  cerebellum.  As  a  rule  only  one  abscess  exists,  and  this  may 
be  so  small  as  to  almost  escape  observation,  or  so  extensive  as  to  destroy 
the  greater  portion  of  a  lobe  of  the  brain.  In  rare  instances  the  abscess 
becomes  encapsulated  and  the  symptoms  gradually  disappear. 


618  DISEASES    OF   THE   BRAIN 

Symptomatology. — Brain  abscess  commonly  begins  with  severe  pain  in 
the  head,  paroxysmal  in  character,  associated  with  projectile  vomiting, 
chills  and  fever.  Irregular  septic  fever,  when  associated  with  recurring 
chilly  sensations,  pain  in  the  head  and  vomiting,  is  a  very  important  symp- 
tom. If  the  above  symptoms  occur  in  a  child  suffering  from  disease  of 
the  internal  ear,  from  mastoiditis,  or  septic  infection  of  the  frontal  or 
ethmoidal  sinuses,  there  is  every  reason  to  suspect  that  an  abscess  of  the 
brain  is  developing  and,  if  an  examination  of  the  eyes  reveals  an  optic 
neuritis,  that  suspicion  will,  in  a  large  degree,  be  confirmed.  Localizing 
symptoms  may  also  occur,  such  as  aphasia  and  paralysis,  or  disturbances  of 
function  of  the  cranial  nerves. 

Diagnosis. — In  many  instances  it  is  impossible  to  make  a  diagnosis, 
but  mistakes  will  be  many  times  avoided  by  keeping  in  mind  the  acute- 
ness  of  the  above  symptom  group  and  remembering  especially  that  the 
headache  and  vomiting  are  associated  with  symptoms  of  general  sepsis, 
such  as  chills,  irregular  fever,  and  a  well-marked  leukocytosis,  and  that 
the  cause  of  this  sepsis  can  commonly  be  located  in  the  ear,  mastoid  or 
sinuses  of  the  face.  A  careful  bacteriological  examination  of  the  cerebro- 
spinal fluid  should  be  made  to  exclude  the  various  forms  of  meningitis. 

Course  and  Duration. — While  the  onset  of  abscess  of  the  brain  is  not 
always  sudden,  after  the  disease  is  once  fully  developed  its  course  is,  as 
a  rule,  rapid,  terminating,  in  the  vast  majority  of  instances,  fatally  within 
two  or  three  weeks.  The  later  stages  of  this  disease  are  marked  by  sub- 
normal temperature,  stupor,  coma,  slow  pulse  and  marked  disturbance 
of  the  respiratory  rhythm. 

Treatment.  — The  treatment  is  purely  surgical.  All  cases  due  to  trauma, 
otitis  media,  mastoiditis  and  sinus  affections  should  be  operated  upon  at 
the  very  earliest  time  possible.  Cases  that  cannot  be  relieved  by  surgical 
measures  are  to  be  treated  in  a  purely  symptomatic  way,  and  opiates 
should  be  given,  if  necessary,  to  relieve  pain. 

CHRONIC  INTERNAL  HYDROCEPHALUS 

Chronic  internal  hydrocephalus  is  due  to  increase  of  serous  fluid  within 
the  ventricles  of  the  brain,  resulting  in  compression  of  brain  substance 
against  the  bony  walls  of  the  cranium.  Under  this  pressure  the  cranium 
enlarges,  if  bony  union  of  the  sutures  of  the  skull  has  not  taken  place; 
this  chronic  internal  form  is  commonly  spoken  of  as  'liydroceplialus." 
(Acute  hydrocephalus  occurs  in  association  with  meningitis,  especially  the 
tuberculous  form,  and  its  symptomatology  is  inseparably  connected  with 
the  acute  meningeal  process  of  which  it  is  a  part,  and  even  in  those  rare 
cases  where  the  inflammation  is  confined  to  the  ependyma  or  lining  mem- 
brane of  the  ventricles,  the  clinical  picture  is  that  of  meningitis,  the  symp- 
tomatology of  which  has  been  elsewhere  considered.)  In  addition  to  the 
chronic  internal  form  there  is  a  condition  known  as  chronic  external  hydro- 
cephalus, in  which  the  fluid  accumulates  between  the  dura  and  arachnoid 


CHRONIC    INTERNAL    HYDROCEPHALUS  619 

and  compresses  the  brain  against  the  floor  of  the  cranial  cavity ;  this  is  an 
inflammation  of  the  dura  and  arachnoid  commonly  associated  with  de- 
fective development  of  the  cerebrum.  Its  comparative  rarity,  however, 
and  the  fact  that  its  symptomatology  does  not  materially  differ  from  the 
chronic  internal  variety,  are  sufficient  reasons  for  disregarding  its  further 
consideration. 

Etiology.— Chronic  internal  hydrocephalus  may  be  congenital  or  ac- 
quired.    Its  etiological  factors  have  not  been  fully  determined.     Inflam- 


FiG.  92. — Idiopathic  Hydrocephalus.     An  unusual  degree  of  cranial  enlargement.     Cir- 
cumference, 40  inches.     (Willard  Knowlton.) 

matory  lesions  perhaps  play  an  important  role  in  producing  the  acquired 
form,  and  developmental  defects  are  believed  to  be  etiologically  related  to 
the  congenital  form.  Czerny  believes  that  pathological  changes,  which 
he  found  in  the  adrenal  bodies,  may  be  a  cause  of  this  condition.  The 
exciting  causes,  whatever  they  may  be,  in  some  instances  close  the  aque- 
duct of  Sylvius  and  the  openings  between  the  Ventricles  of  the  brain, 
thus  interfering  with  the  circulation  of  the  cerebrospinal  fluid.  Neurotic 
inheritance,  congenital  syphilis,  and  tuberculosis  may  be  etiologically  re- 
lated to  this  disease. 

Pathology. — The  essential  pathological  condition  is  an  accumulation 
of  fluid  in  the  ventricles,  which  may  vary  in  quantity  from  a  pint  to  four 
or  five  pints.  The  pressure  of  this  fluid  produces  compression  and  atrophy 
of  the  brain  substance.  The  distention  is  so  great  in  severe  cases  that  the 
brain  is  converted  into  cysts  inclosed  in  thin  walls  of  compressed  brain 
tissue.  Except  in  rare  instances,  where  the  sutures  are  firmly  united,  the 
skull  is  enlarged,  and  under  this  dilatation  the  sutures  gap. 

Symptomatology. — The  most  important  symptom  is  the  increase  in  size 


630  DISEASES    OF   THE    BRAIN 

of  the  head,  which  continues  to  grow  larger  as  the  disease  progresses, 
until  in  a  fully  developed  case  the  great  increase  in  size  of  the  skull  is 
in  marked  contrast  to  the  small,  thin,  wrinkled  face.  The  forehead  is 
high  and  pushes  forward,  the  temporal  and  parietal  bones  spread  outward, 
greatly  increasing  the  lateral  diameters  of  the  head.  The  anterior  fontanel 
is  widely  open,  tense  and  pulsating,  and  the  sutures  leading  from  the 
fontanels  may  have  opened  under  the  pressure.  The  veins  of  the  head  are 
congested  and  prominent.  The  eyes  protrude,  are  turned  downward  and 
have  a  peculiar  stare,  the  cornea  is  partially  covered  by  the  lower  lid,  and 
the  white  sclera  shows  above;  late  in  the  disease,  nystagmus,  strabismus, 
and  even  total  blindness  may  occur.  The  mentality  of  the  child  suffers  as 
the  disease  progresses,  its  expression  becomes  dull  and  stupid,  and  it  loses 
interest  in  its  surroundings.  Its  body  becomes  more  and  more  wasted, 
its  arms  and  legs  assume  a  more  or  less  characteristic  position,  due  to 
rigidity  and  contraction  of  the  tendons  and  muscles.  The  arms  are  flexed, 
the  fingers  and  toes  contracted;  the  reflexes  are  exaggerated,  tremor, 
choreic  movements,  convulsive  twitchings  and  general  eclampsia  may  oc- 
cur, and  the  patient  toward  the  end  may  lie  in  a  helpless  paretic  condition. 
The  most  pronounced  and  severe  cases  are,  as  a  rule,  of  the  hereditary 
form;  in  some  of  these  death  may  occur  m  utero,  or  the  head  may  be  so 
large  at  the  time  of  birth  that  the  child  dies  during  labor;  in  otliers  the 
head  is  only  slightly  enlarged  at  birth,  but  slowly  increases,  until  the 
characteristic  symptoms  are  presented  between  the  second  and  fourth 
months  of  life. 

Prognosis. — Most  of  these  cases  die  in  early  infancy;  a  few  of  the 
milder  ones  recover;  of  those  in  which  spontaneous  cure  takes  place  the 
majority  fail  to  reach  full  mental  development. 

Treatment. — In  those  cases  in  which  hereditary  syphilis  is  a  factor, 
antisyphilitic  treatment  may  favorably  influence  the  progress  of  the  disease, 
and  since  this  is  the  only  form  of  medical  treatment  that  can  be  of  any 
value,  mercury  by  inunction  and  iodid  of  potash  internally  should  be  given 
a  trial  in  every  case  where  there  is  the  slightest  suspicion  of  syphilis. 
Lumbar  puncture  may  in  some  cases  give  decided  relief;  if  so,  it  should 
be  repeated  at  intervals  of  two  or  three  weeks.  Aspiration  of  the  ventricles 
followed  by  pressure  bandages  to  the  head  may  give  temporary  relief.  Many 
other  surgical  measures  have  been  tried,  but  all  have  been  disappointing. 

MENINGOCELE,  ENCEPHALOCELE,  AND  HYDREN- 
CEPHALOCELE 

These  malformations  represent  different  phases  of  congenital  hernia 
of  the  contents  of  the  skull.  The  openings  through  which  the  cranial  con- 
tents protrude  may  be  located  in  the  occipital,  the  nasofrontal,  the  frontal, 
the  temporal  and  parietal  portions  of  the  skull.  The  occipital  region, 
however,  is  by  far  the  most  common  location.  In  some  instances  a  large 
portion  of  the  occipital  bone  is  absent,  the  defect  extending  upward  along 


ENCEPHALOCELE,    HYDRENCEPHALOCELE  621 

the  median  line  to  the  posterior  fontanel  or  downward  to  the  foramen 
magnum.  Through  tliis  opening  the  contents  of  the  skull  protrude,  form- 
ing a  large  or  small  tumor  mass  in  the  median  line  of  the  lower  occipital 
region.  When  the  hernia  protrudes  through  an  opening  in  the  nasofrontal 
region  the  tumor  occupies  the  bridge  of  the  nose.  The  other  most  common 
sites  for  these  hernias  are  along  the  lines  of  the  cranial  sutures. 

MENINGOCELE 

Meningocele  is  the  protrusion  of  the  meninges  or  brain  membranes 
through  the  opening  in  the  skull.  The  protruding  sac  is  commonly  dis- 
tended with  fluid.  This  is  the  rarest  variety  of  cerebral  hernia.  The  open- 
ing in  the  bone  is  usually  small  and  the  tumor  mass  is  small,  pedunculated, 


Fig.  93. — Meningocele,  Encephalocele,  Hydrencephalocele. 

fluctuates  on  palpation,  is  translucent,  presents  no  pulsation  and  is  com- 
monly reducible.  This  tumor  mass,  containing  no  brain  tissue,  is  much 
more  amenable  to  surgical  treatment  than  other  forms  of  cerebral  hernia; 
the  sac  may  be  opened,  its  contents  discharged  and  the  opening  in  the 
skull  closed.  In  all  instances  the  radical  surgical  treatment  of  this  con- 
dition is  to  be  recommended,  but  it  is  advisable  to  delay  the  operation 
for  some  months,  until  the  infant,  on  breast-milk,  has  commenced  to  de- 
velop physically  and  is  in  a  fit  condition  to  withstand  the  shock  of  the 
operation. 

ENCEPHALOCELE 

Encephalocele  is  the  protrusion  of  brain  substance  through  the  opening 
in  the  skull.  The  extruded  cerebral  substance  carries  before  it  the  brain 
membranes.  In  this  form  of  cerebral  hernia  the  tumor  mass  is  com- 
posed of  brain  substance  not  in  communication  with  the  ventricles  of  the 
brain ;  the  only  fluid  that  such  a  tumor  may  contain  is  on  its  outer  sur- 
face between  the  brain  tissue  and  the  membranes  covering  it.  In  these 
cases  the  opening  in  the  skull  is  large  and  the  tumor  comparatively  small 
and  not  pedunculated.  Pulsation  in  the  tumor  is  very  distinct;  it  is  not 
translucent,  and  attempts  at  reduction  are  followed  by  symptoms  of  cere- 
bral compression. 

The  treatment  of  encephalocele  is  very  unsatisfactory;  small  tumor 
masses,  especially  in  the  frontal  region,  should  be  treated  surgically;  the 


622  DISEASES    OF    THE   BRAIN 

sac  should  be  opened,  the  tumor  removed  and  the  opening  in  the  skull 
closed.  Ijargcr  masses  occurring  in  the  occipital  region  are  less  favorable 
for  operation,  but,  notwithstanding  the  great  mortality  which  follows 
the  removal  of  these  tumors,  such  radical  surgical  measures  are  followed 
by  a  greater  percentage  of  recoveries  than  follow  other  methods  of  treat- 
ment. The  injection  of  iodin,  or  other  irritants,  as  well  as  the  expectant 
plan  of  treatment,  offers  even  slighter  chances  of  recovery.  The  removal 
of  the  tumor  is  to  be  advised  in  all  infants  suffering  from  encephalocele 
who  have  lived  past  the  sixth  month  of  life,  and  during  this  time  have 
gained  in  nutrition  and  have  commenced  to  show  symptoms  of  normal 
mental  development.  Large  tumors  associated  with  other  congenital  de- 
fects occurring  in  infants  who  fail  to  develop  both  physically  and  men- 
tally should  be  considered  inoperable. 

HYDEENCEPHALOCELE 

Hydrencephalocele  commonly  occurs  in  the  lower  occipital  region; 
this  is  the  most  frequent  and  the  worst  form  of  cerebral  hernia.  The 
tumor  mass  in  these  cases  is  made  up  of  brain  membranes,  covering  the 
protruding  brain  substance,  which  contains  a  cavity  filled  with  fluid  in 
direct  communication  with  the  ventricles  of  the  brain. 

As  these  cases  are  inoperable  it  is  important  that  they  should  be  differ- 
entiated from  encephalocele,  and  this  differentiation  may  be  made  with 
a  fair  degree  of  accuracy  by  the  following  symptom  group :  The  tumor 
is  large,  sometimes  five  or  six  inches  in  diameter ;  it  is  faintly  translucent ; 
deep  fluctuation  is  present ;  it  is  pedunculated,  pendulous,  irreducible,  and 
its  surface  is  irregular  and  offers  little  resistance  to  palpation.  The  skull 
is  commonly  deformed,  giving  to  the  eye  the  impression  of  imbecility. 
In  doubtful  cases  deep  aspiration  of  the  tumor  reveals  the  presence  of 
fluid. 

The  prognosis  is  absolutely  bad ;  surgical  treatment  is  contraindicated, 
and  symptomatic  medical  treatment  can  only  promote  the  comfort  and 
prolong  the  life  of  the  patient. 

IDIOCY 

Mental  deficiency,  imbecility  and  idiocy  are  terms  used  to  represent 
various  degrees  of  mental  impairment  due  to  congenital  defects,  disease 
and  injury  of  the  undeveloped  brain  of  the  infant,  with  an  associated  lack 
of  development  on  the  part  of  the  general  nervous  system. 

Etiology. — Idiocy  may  be  either  congenital  or  acquired,  althoiigli  it 
is  difficult  to  conform  to  this  or  any  other  classification  in  describing  a 
condition  with  such  widely  varying  etiological  factors. 

Congenital  idiocy  is  due  to  development  defects  of  the  brain,  such 
as  porencephalus,  agenesis  corticalis,  and  other  little  imderstood  condi- 
tions. These  cases  represent  the  worst  types  of  idiocy  and  are  very  fre- 
quently associated  with  other  congenital  malformations  and  with  the  stig- 


IDIOCY  623 

mata  of  cle<]:enoration  in  other  parts  of  the  body.  They  are  also  etiologi- 
callj  related  to  ])arental  alcoholism,  syphilis,  hysteria,  insanity,  epilepsy 
and  chorea.  It  is  believed  that  consanguinity  of  parents,  as  in  the  mar- 
riage of  first  cousins,  may  predispose  to  idiocy  by  exaggerating  the  family's 
neiiropatliic  taint,  thereby  exaggerating  congenital  defects.  Cerebral  hem- 
orrhage occurring  before  or  at  birth,  and  followed  by  spastic  paraplegia 
and  diplegia,  is  one  of  the  common  causes  of  mental  deficiency  and  im- 
becility (see  Cerebral  Palsies).  Microeephalus  is  associated  with  one  of 
the  worst  types  of  idiocy  and  hydrocephalus  may  produce  mental  defi- 
ciency and  imbecility. 

The  acquired  forms  of  idiocy  are  due  to  the  following  causes:  cerebral 
hemorrhage,  meningitis,  encephalitis,  epilepsy,  eclampsia,  traumatism  and 
asphyxia. 

Symptomatology. — Mental  deficiency,  no  matter  how  marked  it  may 
be,  is  rarely  recognized  during  the  first  months  of  life,  except  in  the  Mon- 
golian type  of  this  disease.  Defective  infants  are  believed  to  be  normal 
in  the  great  majority  of  instances,  until  the  time  arrives  when  it  is  evi- 
dent, even  to  the  mother,  that  the  infant  does  not  handle  its  body,  use  its 
arms  and  legs,  and  otherwise  act  as  normal  infants  do.  When  it  is  per- 
haps six  months  of  age  the  attendants  notice  that  its  body  is  limp,  and 
that  it  makes  no  effort  to  hold  up  its  head  or  straighten  its  spine.  As 
time  passes  it  may  become  evident  that  the  infant  fails  to  distinguish 
between  the  faces  that  constantly  surround  it;  it  does  not  recognize  its 
mother.  During  the  second  year  of  life,  instead  of  uttering  words  that 
have  been  repeated  to  it,  it  makes  strange  sounds  or  perhaps  utters  shrill 
cries,  and  all  of  its  actions  are  without  purpose  or  intent.  It  fails  to 
grasp  at  or  take  hold  of  its  nursing  bottle,  is  unable  to  lift  itself  in  bed, 
and,  even  toward  the  end  of  the  second  year,  makes  no  effort  to  walk.  In 
the  early  stages  of  this  condition  these  signs  of  lack  of  physical  develop- 
ment are  more  evident  than  symptoms  due  to  lack  of  mental  development, 
but  as  the  child  grows  older  the  mental  defects  become  evident.  The  facial 
expression  in  almost  every  instance  bears  the  mark  of  stupidity  and  lack 
of  intelligence  to  everyone  except  the  mother,  and  perhaps  those  who  have 
been  constantly  associated  with  the  child  from  birth.  On  the  one  hand 
the  child  may  be  stupidly  amiable,  never  crying,  easily  amused,  knowing 
no  fear,  making  friends  with  everyone,  and  quite  as  happy  when  amused 
by  strangers  as  when  it  is  with  its  mother;  or  again  it  may  be  irritable, 
easily  frightened  and  uncontrollable.  The  degree  of  mental  deficiency  will 
vary  greatly  with  the  extent  and  severity  of  the  brain  injury  which  pro- 
duces it.  In  many  of  the  acquired  cases,  especially  those  associated  with 
cerebral  hemiplegia,  the  child  has  a  fair  degree  of  intelligence,  and  the 
mental  development  in  these  cases  may  be  greatly  improved  by  careful, 
systematic  training.  In  other  instances,  especially  those  associated  with 
congenital  brain  defects,  intellectual  activity  may  be  almost  or  totally 
lost.  Such  cases  have  no  idea  of  personal  cleanliness,  eat  their  food  in 
a  ravenous  manner  when  it  is  fed  to  them,  fail  to  acquire  the  faculty  of 
41 


624  DISEASES    OF    THE   BRAIN 

speech,  and  make  strange  uncouth  noises  that  have  no  relevancy  to  their 
surroundings. 

Prognosis. — The  prognosis  in  all  of  these  cases  is  bad  so  far  as  total 
recovery  is  concerned,  but  from  the  standpoint  of  partial  recovery  the 
prognosis  depends  upon  the  character  and  extent  of  the  lesion.  The  con- 
genital cases  due  to  defective  development  of  the  brain  are  hopeless.  Those 
due  to  cerebral  hemorrhage  and  associated  with  diplegia  and  paraplegia 
are  also  hopeless,  but  those  associated  with  hemiplegia,  as  previously  noted 
under  Cerebral  Palsies,  may  have  a  fair  degree  of  development.  Those 
due  to  inflammatory  conditions  of  the  brain  and  meninges  may  be  only 
partially  defective,  and  those  cases  associated  with  epilepsy  may  suffer 
from  very  slight  or  very  marked  mental  deficiency. 

Treatment.' — Hopeless  cases  are  better  cared  for  in  institutions,  where 
they  will  be  much  happier  than  in  their  own  homes,  and  where  they  will 
not  have  an  unfavorable  influence  upon  the  other  children  in  the  family. 
Feebleminded  or  slightly  defective  children  should  be  placed  under  the 
care  and  direction  of  teachers  who  have  been  especially  educated  for  this 
kind  of  work.  Under  the  care  of  intelligent  specialists  the  best  possible 
results  in  the  mental  development  of  these  children  can  be  obtained. 
The  late  Dr.  Christopher,  of  Chicago,  did  excellent  service  by  helping  to 
establish  a  special  system  of  education  for  defective  children  in  connection 
with  the  public  schools  of  Chicago.  These  defectives  were  separated  from 
the  normal  children  in  the  public  schools,  were  properly  classified  and 
placed  under  competent  instructors.  Nearly  all  of  the  large  cities  of  our 
country  are  beginning  to  recognize  the  importance  of  furnishing  to  the 
defective  children  of  the  poor  an  education  which  will  develop  the  best 
that  is  in  them  and  possibly  make  them  self-supporting  in  after  life. 

AMAJJEOTIC    FAMILY    IDIOCY 

The  etiology  of  this  condition  is  unknown;  it  is  congenital,  and,  al- 
though a  rare  disease,  more  than  one  case  may  occur  in  the  same  family. 

At  birth  the  child  is  apparently  healthy,  but  at  six  or  eight  months 
of  age  physical  and  mental  defects  are  observed.  It  does  not  use  its  body 
and  limbs  as  normal  children  do,  and  shows  absolutely  no  sign  of  mental 
development.  Nystagmus  occurs  and  blindness  gradually  results  from 
atrophy  of  the  optic  nerve.  An  ophthalmoscopic  examination  shows  red 
spots  on  a  grayish-white  opacity  in  the  region  of  the  fovea  centralis.  A  con- 
dition of  absolute  idiocy  is  presented,  the  child  has  no  mental  perceptions, 
spastic  paraplegia  may  develop,  progressive  emaciation  occurs,  and  the 
disease  invariably  ends  in  death,  usually  before  the  end  of  the  second  year. 

MONGOLIAN    IDIOCY 

The  cause  of  this  condition  is  unknown,  but  its  most  striking  symp- 
tom is  the  fades,  which  is  characteristic  of  this  disease,  and  by  it  the 
diagnosis  is  made.     The  facies  consist  in  a  Mongolian  or  Chinese  tyjje  of 


IDIOCY  625 

face,  characterized  by  the  downward  slant  of  the  palpebral  fissures  toward 
the  nose,  which  is  broad  and  low.  The  cheeks  are  full  and  high-colored; 
the  skin  and  hair  normal;  the  tongue,  although  not  swollen,  lolls  out  of 
the  mouth  as  it  does  in  the  cretin.  The  head  is  flat,  the  fontanels  remain 
open  longer  than  usual,  and  the  skull  is  brachycephalic  and  below  the 
average  in  circumference.  The  hands  are  short ;  this  is  especially  noticeable 
in  the  thumb  and  little  finger;  the  latter  curving  inward  over  the  ring 
finger  is  a  sign  of  diagnostic  importance  in  differentiating  this  disease 
from  cretinism.  The  characteristic  facies  above  described  may  be  notice- 
able soon  after  birth,  and  by  it  the  physician  may  be  able  to  foresee  the 
subsequent  development  of  Mongolian  idiocy. 

These  Mongols  as  they  grow  older  show  not  only  delayed  physical  de- 
velopment but  marked  lack  of  mental  power.  They  teethe  slowly  and  are 
late  in  getting  control  of  their  arms,  legs  and  body,  so  that  they  may  be 
four  or  five  years  of  age  before  they  walk  with  ease.  From  this  time  on 
their  mental  defects  are  much  more  noticeable,  but,  as  a  rule,  they  con- 
tinue to  slowly  improve  in  intellectuality,  being  classed  as  very  backward 
children.  At  three  or  four  years  of  age  they  may  understand  what  is  said 
to  them,  be  able  to  repeat  simple  words,  play  with  their  toys,  be  inter- 
ested in  their  surroundings,  and  may  finally  reach  a  stage  of  mental  de- 
velopment which  enables  them  to  look  after  their  personal  wants,  observe 
ordinary  habits  of  cleanliness,  and  even  learn  to  read  and  write,  but  be- 
yond this  little  is  to  be  hoped  for. 

Treatment. — There  is  no  medical  treatment  that  favorably  influences 
this  condition.  The  treatment  of  these  children,  therefore,  consists  in 
looking  carefully  to  their  mental  and  physical  development.  Their  men- 
tal development  can  be  favorably  influenced  by  placing  them  under  the 
care  and  direction  of  competent  teachers,  who  have  been  trained  for  this 
work. 

MICROCEPHALIC   IDIOCY 

In  this  form  of  idiocy  the  head  presents  a  characteristic  deformity. 
The  circumference  of  the  cranium  is  small,  the  forehead  is  very  low  and 
sharply  recedes  into  a  poorly  developed  occipital  prominence,  the  fontanels 
are  closed,  the  sutures  prematurely  ossified,  and  the  face  is  proportion- 
ately large,  giving  the  head  a  peculiar  bird-shaped  appearance,  stamped 
with  an  expression  of  absolute  idiocy.  The  primary  pathological  lesion 
in  these  cases  is  situated  in  the  brain;  a  microcephalic  brain  may  even  be 
incased  in  a  normal  cranium.  The  small  skull  in  most  of  these  cases  has 
absolutely  nothing  to  do  with  arresting  the  growth  of  the  brain.  The  ar- 
rested development  of  the  brain,  like  the  perverted  development  of  the 
cranium,  is  due  to  developmental  defects.  In  some  instances  there  may 
be  a  lack  of  development  of  the  whole  brain.  In  other  cases  the  occipital, 
the  parietal  or  the  frontal  lobes  may  be  undeveloped,  and  the  small  and 
prematurely  ossified  cranium  is,  as  a  rule,  more  commodious  than  the 
atrophied  brain  demands.  Operation  upon  the  skull,  to  increase  the  capacity 


626  MENINGITIS 

of  the  cranium  and  allow  the  brain  to  grow,  is  founded  upon  an  erroneous 
conception  of  this  disease,  and  does  absolutely  no  good. 

Microcephalic  idiocy,  as  the  term  is  commonly  used,  merely  refers  to 
a  type  of  hopeless  and  almost  complete  idiocy  in  which  the  atrophied, 
diseased  and  deformed  brain  is  inclosed  in  a  microcephalic  skull  and  does 
not  definitely  determine  the  character  or  location  of  the  brain  deformity. 
The  multiplicity  of  brain  lesions  which  exist  in  these  cases  explain  the 
fact  that  in  some  instances  the  rest  of  the  body  may  be  normally  developed 
and  the  patients  may  live  past  middle  life,  while  in  other  instances  spas- 
tic and  flaccid  paralysis  may  exist  and  the  duration  of  the  disease  may  be 
much  shorter. 

Treatment. — There  is  no  treatment,  either  medical  or  surgical,  that 
favorably  influences  the  course  of  this  disease. 


CHAPTER    LXXIX 
MENINGITIS 

Meningitis  is  an  infectious  disease  producing  inflammation  of  the  pia 
mater  and  arachnoid  membranes  of  the  brain  and  spinal  cord.  For  clin- 
ical reasons  the  various  forms  of  this  disease  are  here  grouped  under  one 
heading. 

In  the  present  state  of  our  knowledge  it  is  impossible  to  make  a  satis- 
factory clinical  classification  of  the  different  forms  of  meningitis.  The 
syndromes  presented  by  the  various  forms  so  closely  resemble  one  another 
that  a  classification  based  on  clinical  phenomena  alone  is  absolutely  im- 
possible. In  this  dilemma  it  is  perhaps  better  for  text-book  purposes  to 
adopt  the  classification  now  in  vogue  based  upon  clinical,  bacteriological 
and  pathological  findings.  It  recognizes  three  varieties,  the  differential 
diagnosis  of  which  can  nearly  always  be  made  by  an  examination  of  the 
cerebrospinal  fluid,  studied  in  connection  with  the  clinical  syndromes 
which  the  various  forms  of  meningitis  present. 

This  classification  is  as  follows : 

1.  Tuberculous  meningitis,  produced  by  the  tubercle  bacillus. 

2.  Epidemic  cerebrospinal  meningitis,  produced  by  the  meningococcus 
intracellularis. 

3.  Purulent  meningitis,  a  term  used  to  include"  all  forms  not  produced 
by  the  tubercle  bacillus  or  meningococcus. 

TUBERCULOUS  MENINGITIS 

Pathology.— This  form  of  meningeal  inflammation  is  produced  by  the 
tubercle  bacillus  and  its  general  etiology  is  the  same  as  that  of  other  forms 
of  tuberculosis.  The  meninges  are  soon  studded  with  small  gray  tubercles 
usually  attached  to  the  blood  vessels.     A  thick,  yellow,  inflammatory  exu- 


TUBERCULOUS    MENINGITIS  627 

date  forms  over  the  base  of  the  brain,  and  extends  with  the  Wood  vessels  in 
the  sulci  which  lead  toward  the  convexity  of  the  brain.  The  ventricles 
are  distended,  j^roducing  internal  hydrocephalus;  the  gradually  increasing 
hydrocephalus  produces  intracranial  pressure,  pushing  with  considerable 
force  the  convolutions  of  the  brain  against  the  unyielding  bony  wall  of  the 
cranium.  The  l^rain  tissue  just  beneath  the  meninges  may  contain  caseous 
nodules  which  sometimes  reach  the  size  of  a  hen's  egg.  These  tubercu- 
lous tumor  masses  may  produce  localizing  symptoms.  The  meningeal  in- 
flammation may  not  only  involve  the  cervical  region  of  the  cord,  but  may 
extend  along  the  entire  spinal  canal. 

Tuberculous  meningitis  occurs  most  frequently  in  infancy  and  early 
childhood ;  about  70  per  cent,  of  the  cases  are  seen  between  the  end  of  the 
first  and  the  fifth  years  of  life.  It  is  the  cause  of  death  in  20  to  30  per 
cent,  of  all  cases  dying  of  tuberculosis  under  five  years  of  age,  and  at  this 
period  of  life  it  comprises  about  70  per  cent,  of  all  cases  of  meningitis, 
except  when  the  epidemic  form  is  prevalent.  It  is  commonly  secondary 
to  lymph-node,  pulmonary,  and  general  miliary  tuberculosis,  but  may  re- 
sult from  tuberculous  foci  anywhere  in  the  body,  the  blood  and  lymph 
streams  being  the  carriers  of  the  tubercle  bacilli  to  the  meninges;  in 
nearly  every  instance  the  infecting  organism  is  of  the  human  type.  It  is 
rarely,  if  ever,  a  primary  disease,  but  may  spread  from  bony  cavities  in 
the  face,  nose  and  ear,  with  no  preliminary  tuberculous  disease  elsewhere 
in  the  body. 

Symptomatologfy. — In  infancy  tuberculous  meningitis  is  commonly  a 
manifestation  of  a  general  tuberculosis  and  is  not,  as  a  rule,  preceded  by 
premonitory  symptoms  due  to  tuberculosis  elsewhere  in  the  body.  After 
the  second  year  of  life,  however,  it  is  generally  very  insidious  in  its  onset 
and  is  preceded  by  the  symptoms  of  lymph-node,  bone,  lung  or  general 
miliary  tuberculosis.  Its  symptoms,  especially  in  children  over  three  years 
of  age,  may  be  divided  into  three  groups  representing  the  stages  of  in- 
vasion, irritation  and  compression.  It  must  be  remembered,  however,  that 
while  the  symptoms,  for  clearness  of  presentation,  are  here  described  under 
these  three  groups,  the  symptomatology  of  this  disease  does  not  by  any 
means  always  follow  this  regular  course.  On  the  other  hand,  the  variabil- 
ity and  irregularity  of  the  symptoms  are  notable  characteristics  of  tuber- 
culous meningitis. 

The  STAGE  OF  INVASION  is  marked  by  fever,  vomiting,  constipation, 
great  nervous  irritability,  sleeplessness,  loss  of  weight  and  general  pros- 
tration, none  of  which  are  especially  characteristic  of  this  disease;  but  a 
combination  of  some  or  all  of  these  symptoms  is  especially  suggestive 
when  they  occur  in  a  child  who  has  tuberculous  foci  elsewhere  in  the  body, 
or  who  has  lived  under  conditions  which  have  repeatedly  exposed  it  to  the 
tuberculous  contagion.  The  vomiting  occurring  and  recurring  without 
apparent  cause  is  the  symptom  which  gives  special  importance  to  this  symp- 
tom group.  The  temperature  during  this  period  is  usually  overlooked, 
and  varies  from  normal  to  101  °F.     The  Moro  and  von  Pirquet  skin  re- 


628  MENIN^GITIS 

actions  are  nearly  always  present  during  this  stage.  These  symptoms  may 
continue,  especially  in  older  children,  two  or  three  weeks,  and  during  this 
time  the  child  may  have  days  of  apparent  convalescence,  but  its  general 
condition  steadily  grows  worse  until  the  stage  of  irritation  presents  the 
following  more  characteristic  symptoms:  An  increase  in  the  fever  to 
101°  or  1 02  °F.  occurs,  but  the  temperature,  as  a  rule,  does  not  run  high 
unless  there  be  other  tuberculous  lesions.  The  restlessness  gives  way  to 
mental  dullness  and  stupor,  which  may  alternate  with  extreme  nervous 
irritability  and  may  be  associated  with  a  mild  delirium;  convulsions, 
either  general  or  local,  may  occur;  muscular  rigidity,  producing  retraction 
of  the  neck  and  stiffness  of  the  spine,  appears;  localized  facial  palsy  and 
spastic  paralysis  of  the  extremities  may  come  and  go;  Kernig's  sign  is 
present  sooner  or  later  in  the  majority  of  cases,  but  is  not  so  frequent  as 
in  other  forms  of  meningitis;  Babinski's  reflex  is  slightly  more  common 
in  this  form  of  meningitis  than  in  any  other,  and  is,  therefore,  in  cliil- 
dren  over  two  years  of  age,  a  sign  of  some  value  in  differential  diagnosis. 
The  pupils  may  be  unequal  and  respond  slowly  or  not  at  all  to  light; 
strabismus  is  a  common  and  a  very  suggestive  sign;  nystagmus  may  be 
noted  among  the  earliest  eye  symptoms,  and  the  ophthalmoscope  may  reveal 
an  optic  neuritis  with  bright  shining  tubercles  in  the  choroid.  Vaso- 
motor disturbances  are  common,  red  patches  involving  the  ear  or  other 
portions  of  the  body  may  come  and  go  without  apparent  cause,  and  a  red 
streak  may  be  brought  out  by  drawing  the  finger  over  any  portion  of  the 
body;  the  petechial  eruption  is  absent.  The  respiratory  rhythm  is  dis- 
turbed; the  respirations  are  irregular  and  marked  by  periods  in  which  the 
respiratory  movements  are  suspended;  gradually  a  Cheyne-Stokes  type  of 
breathing  may  be  developed.  The  pulse  may  be  slow  and  intermittent. 
This  stage  may  last  a  week,  more  or  less,  depending  upon  the  age  of  the 
child  and  the  severity  of  the  disease.  During  this  time  there  may  be  great 
variations  in  this  symptom  group.  It  is  not  an  uncommon  experience  to 
find  that  a  child  that  has  been  for  a  number  of  days  profoimdly  stuporous 
and  almost  or  quite  unable  to  swallow  food,  rather  suddenly  recovers 
consciousness  and  again  swallows  his  food  in  a  normal  manner.  This  ap- 
parent improvement  causes  the  attendants  to  hope  that  the  child  is  really 
better,  when  after  a  few  hours  the  stupor  returns  and  the  whole  symptom 
group  gradually  grows  worse,  until  the  third  stage  of  the  disease  arrives 
with  symptoms  of  cerebral  compression.  The  coma  deepens;  unconscious- 
ness is  complete;  the  muscular  spasm  is  relaxed;  stiffness  of  the  muscles 
of  the  spine  disappears;  general  paralysis,  permanent,  and  of  the  flaccid 
type,  is  widespread;  deglutition  becomes  more  difficult  and  at  times  im- 
possible; the  eyelids  are  partially  closed,  the  pupils  widely  dilated,  and  the 
eyeballs  turned  upward.  The  pulse  is  very  rapid  and  weak;  the  breathing 
becomes  more  rapid,  more  irregular,  and  the  respiratory  pauses  are  more 
noticeable.  The  temperature,  which  has  run  a  low  range  throughout  the 
disease,  rarely  rising  above  102°  or  103°F.,  toward  the  end  of  the  disease 
may  rise  to  105°  or  106°F.     A  deepening  coma  not  infrequently  accom- 


TUBERCULOUS    MENINGITIS  629 

panicfl  by  convulsions  terminates  the  clinical  picture.  This  stage  lasts 
from  a  few  days  to  one  week. 

The  above  symptom  group  is  subject  to  many  variations,  largely  de- 
termined by  the  age  of  the  child  and  the  virulency  of  the  pathologic 
process.  The  average  duration,  not  counting  the  vague  prodromal  symp- 
toms, is  two  weeks  in  young  infants  and  three  weeks  in  older  children; 
other  things  being  equal,  the  younger  the  child  the  more  rapid  and  the 
more  violent  will  be  the  course  of  the  disease. 

Diagnosis.— The  diagnosis  of  tuberculous  and  other  forms  of  meningitis 
depends  upon  the  careful  study  of  the  above  symptom  group  in  connection 
with  the  individual  case;  giving  special  attention  to  the  family  history. 


DAY 
OF  MONTH 

29 

30 

31 

1 

7 

3 

4 

s 

6 

7 

8 

9 

10 

II 

12 

3      14 

IS 

DAY 
OF  DISEASE 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

II 

12 

13 

14 

IS     1 

6      17 

18 

107° 
106° 
105° 

S     104° 

3 

S     '03° 
a 

u     102° 

»- 

1     lOI° 

z 
u 
s     100 

i 

99° 
98° 
97° 

- 

- 

1 

1 

1 

K 

1 

\ 

\ 

r^ 

f 

> 

\ 

\, 

^ 

V 

"\ 

I 

V 

^ 

A 

S. 

' 

] 

A 

!\ 

1 

I 

\ 

l\ 

i  \ 

, 

J 

V 

A 

1 

\l 

\ 

f  \ 

, 

1 

^ 

r 

PUISE 

■s. 

Z    " 

S 

? 

s  s 

?  1 

S 

s 

g 

£ 

i 

s 

s 

: 

£   '. 

'  s 

s 

i 

z 

£   < 

.  s  : 

RESPIRATION 

t 

s  s 

S 

LI 

S   5 

c     t 

: 

s 

S 

£ 

s 

s 

o 

S 

■s  i 

s 

s 

s 

s 

S  i 

s  s 

s  s 

« 

FiQ.  94. — Tuberculous  Meningitis  in  Child  Twenty  Months  Old. 

the  opportunities  for  contracting  the  tuberculous  contagion,  the  presence  of 
tuberculous  foci  elsewhere  in  the  body,  the  slow  onset  of  the  disease,  the 
low  range  of  temperature;  the  character  of  the  breathing,  the  eye  symp- 
toms, the  ophthalmoscopic  findings,  the  presence  of  Moro's  and  von  Pir- 
quet's  tuberculin  skin  reactions  in  the  early  stages,  and,  most  important  of 
all,  the  finding  of  tubercle  bacilli  in  the  cerebrospinal  fluid;  with  careful 
technique  this  may  be  accomplished  in  the  majority  of  cases.  The  diag- 
nosis may  still  further  be  confirmed  by  producing  tuberculosis  in  the 
guinea  pig  by  inoculating  it  with  the  cerebrospinal  fluid. 

Concerning  the  diagnostic  importance  of  a  careful  examination  of  the 
cerebrospinal  fluid,  Dunn  states  that :  "The  order  in  which  the  inferences 
are  made  during  such  an  examination  is  as  follows :  if  the  fluid  is  cloudy, 
some  form  of  meningitis  is  present;  if  clear,  no  form  of  meningitis  can 


630  MENINGITIS 

be  present,  except  the  tuberculous.  If  the  cell  count  is  normal  (under 
ten  per  cubic  millimeter),  no  meningitis  is  present;  if  the  cell  count  is 
increased  (over  ten  per  cubic  millimeter  and  usually  over  one  hundred  per 
cubic  millimeter),  some  form  of  meningitis  is  present.  If,  with  menin- 
gitis present,  the  predominating  cell  is  the  mononuclear  lymphocyte,  the 
evidence  points  toward  the  tuberculous  form;  if  the  predominating  cell  is 
polymorphonuclear,  the  evidence  points  toward  some  other  form.  The 
differentiation  of  these  other  forms  depends  on  the  finding  of  the  specific 
etiologic  microorganisms  in  the  cerebrospinal  fluid.  The  diplococcus 
intracellularis  and  the  influenza  bacillus  are  recognized  by  their  morphology 
and  their  Gram-negative  staining  reaction;  the  former  also  is  frequently 
seen  within  the  leukocytes.  The  pneumococcus,  streptococcus,  and  staphy- 
lococcus are  recognized  by  their  morpholog}^  and  their  Gram-positive 
staining  reaction.  The  tubercle  bacillus  is  recognized  by  its  special  staining 
reaction.  The  chief  difficulty  is  in  distinguishing  the  pneumococcus  from 
the  staphj'lococcus  form,  from  the  fact  that  the  former  frequently  shows 
a  chain  formation,  and  its  capsule  is  difficult  to  demonstrate  in  the  cerebro- 
spinal fluid.  Nevertheless,  this  difficulty  is  not  so  great  in  the  cerebro- 
spinal fluid  as  under  some  other  conditions.  In  meningitis  the  streptococ- 
cus usually  forms  long  chains  and  its  morphology  is  unmistakable,  while 
the  pneumococcus  frequently  is  seen  in  short  chains;  its  typical  form  as 
a  lance-shaped  diplococcus  is  usually  plainly  evident.  The  positive  proof 
of  the  existence  of  tuberculous  meningitis  is  also  often  difficult,  as  bacilli 
cannot  always  be  found.  We  are  obliged  to  depend  on  the  increased  cell 
count,  with  the  preponderance  of  lymphocytes.  Where  the  cell  count  is 
only  moderately  increased  some  doubt  of  the  diagnosis  will  remain.  Also 
the  cell  count  in  the  cerebrospinal  fluid  is  increased  in  some  other  condi- 
tions which,  however,  are  not  of  a  kind  usually  mistaken  for  tuberculous 
meningitis.  The  existence  of  an  increased  number  of  mononuclear  cells 
is  sufficient  for  ordinary  clinical  purposes,  but  if  the  bacilli  are  not  found, 
it  cannot  be  taken  as  absolute  proof  sufficient  for  scientiflc  purposes." 

Prognosis. — This  is  almost  hopeless.  A  very  few  cases  of  recovery, 
however,  with  well-established  diagnoses,  are  reported  each  year. 

Treatment. — Since  under  existing  forms  of  treatment  the  prognosis  in 
these  cases  is  almost  hopeless,  they  should  be  treated  symptomatically,  as 
outlined  under  meningococcus  meningitis.  The  specific  serum,  however,  of 
this  latter  disease  is  of  absolutely  no  value  in  the  treatment  of  any  other 
form  of  meningitis.  The  possibility,  however,  that  there  may  be  a  mistake 
in  diagnosis,  and  the  fact  that  a  small  percentage  of  cases  of  tuberculous 
meningitis  recover,  should  stimulate  the  physician  to  the  application  of  all 
remedies  which  ameliorate  symptoms  and  prolong  life.  Early  and  repeated 
lumbar  puncture  is  believed  by  Dunn  to  exercise  a  favorable,  and  perhaps 
a  curative,  influence  in  rare  instances. 


MENINGOCOCCUS    MENINGITIS  631 


MENINGOCOCCUS  MENINGITIS 

Meningococcus  meningitis  is  an  acute  infectious,  feebly  contagious 
disease  caused  by  the  diplococcus  intracellularis  meningitidis.  It  occurs 
both  sporadically  and  epidemically,  and  is  characterized  by  a  general  sys- 
temic intoxication  and  the  symptoms  of  a  violent  inflammation  of  the 
pia  mater  and  arachnoid  membranes  of  the  brain  and  spinal  cord. 

Etiology.— The  specific  microorganism  of  this  disease  was  first  de- 
scribed by  Weichselbaum  in  1887.  It  is  found  in  the  mucous  discharges 
from  the  nose  and  throat,  in  the  blood  and  in  the  cerebrospinal  fluid  of 
infected  individuals,  and  may  also  be  demonstrated  on  the  mucous  mem- 
branes of  the  throat  and  nose  of  healthy  individuals,  who  are  closely  as- 
sociated with  patients  ill  of  this  disease.  These  "meningococcus  carriers," 
it  is  believed,  may  carry  the  infection  to  susceptible  individuals.  It  is 
thought  that  this  diplococcus  finds  its  portal  of  entrance  to  the  human  body 
through  the  nose  and  throat,  and  is  disseminated  by  the  mucous  discharges 
from  the  respiratory  passages  or  by  the  careless  handling  of  cerebrospinal 
fluid  drawn  for  therapeutic  or  diagnostic  purposes.  But,  notwithstand- 
ing the  apparent  danger  of  spreading  the  disease  in  this  way,  long  experi- 
ence has  taught  that  there  is  little  actual  danger  from  contact  contagion 
such  as  exists  in  the  other  acute  infections.  That  the  disease  is  but  feebly 
contagious  is  demonstrated  by  the  fact  that  these  cases  have  always  been 
treated  in  the  general  wards  of  our  hospitals,  and  until  the  discovery  of 
its  specific  cause,  clinicians  had  scarcely  suspected  that  there  was  any  great- 
er danger  of  direct  contagion  from  this  form  of  meningitis  than  from  any 
other.  The  slight  contagiousness  may  be  due  to  the  lack  of  individual  sus- 
ceptibility and  to  the  "brief  vitality"  of  the  specific  contagion.  On  the 
other  hand,  one  must  recognize  the  fact  that  the  contagion  is  at  times 
very  widely  disseminated,  producing  extensive  epidemics.  Minor  epi- 
demics have  occurred  in  all  of  our  large  cities,  and  have  also  been  reported 
from  country  districts  and  small  towns  remote  from  great  centers  of  popu- 
lation. In  the  intervals  between  these  epidemics  the  disease  occurs  sporad- 
ically throughout  the  land,  now  and  then  appearing  in  different  parts  of  the 
same  city,  or  perhaps  as  isolated  cases  in  lone  farm  houses.  The  prankish 
vagaries  of  this  contagion  are  yet  to  be  explained. 

Age. — The  disease  is  rare  in  infancy,  although  Rotch  reports  a  case 
in  an  infant  six  days  old.  After  the  first  year  of  life,  however,  it  is  not 
uncommon,  and  childhood  is  the  period  of  greatest  susceptibility.  It  is 
comparatively  infrequent  in  the  adult. 

Season. — It  occurs  most  commonly  in  the  spring  of  the  year;  more 
cases  are  seen  during  March  and  April.  It  is  less  commonly  observed 
during  the  summer  months.  It  is  believed  that  the  low  vitality  of  children 
at  this  period  of  the  year  may  make  them  more  susceptible. 

Pathology. — This  disease  is  characterized  by  an  infection  of  tlte  pia 
mater  and  arachnoid  with  the  encapsulated  diplococcus  of  this  disease. 


632  MENINGITIS 

These  microorganisms  are  found  in  the  polynuclear  leukocytes  which  are 
thrown  out  in  great  numbers,  and  in  the  cerebrospinal  fluid  which  is  greatly 
increased  in  quantity.  These  brain  membranes  are  in  the  beginning  in- 
tensely congested,  and  this  hyperemia  is  followed  by  a  serofibrinous  and 
seropurulent  exudate  which  collects  at  the  base  of  the  brain  and  in  the 
ventricles  and  may  extend  over  the  cortex  and  down  the  spinal  canal.  The 
fluid  found  in  the  ventricles  and  cerebrospinal  canal  quickly  becomes 
clouded  with  pus  corpuscles,  and  later  may  become  a  distinctly  purulent 
fluid. 

In  the  foudroyant  cases  the  patient  may  die  before  the  inflammatory 
lesions  are  marked.  In  such  cases  the  brain  membranes  may  show  only 
intense  congestion  with  a  serous  exudate.  In  the  less  severe  cases  the 
process  lasts  longer  and  a  decidedly  purulent  exudate  may  be  present.  In 
the  more  or  less  chronic  cases  lasting  for  weeks  the  pia  mater  and  arach- 
noid are  thickened  and  bound  to  the  brain  by  an  inflammatory  exudate. 

Symptomatology. — Onset. — In  Ruber's  careful  analysis  of  100  cases, 
only  3  presented  prodromal  symptoms.  In  these  the  more  acute  symp- 
toms were  preceded,  by  a  few  hours,  with  malaise,  headache,  loss  of  appe- 
tite, indefinite  pains,  chilliness  and  slight  rise  of  temperature.  In  all  of 
the  others  the  onset  was  sudden,  and  in  many  the  exact  hour  when  the 
acute  symptoms  began  was  named.  There  is  perhaps  no  other  disease  in 
which  the  onset  is  so  uniformly  sudden  and  violent  as  it  is  in  cerebrospinal 
meningitis.  The  disease  commonly  begins  with  vomiting,  chilliness,  severe 
headache,  and  rapid  rise  of  temperature.  To  this  symptom  group  is  some- 
times added  convulsions,  which  are  especially  common  in  young  children. 
A  petechial  eruption  may  occur.  Spinal  pain  and  tenderness  associated 
with  general  hyperesthesia  may  cause  the  patient  to  cry  with  pain  whenever 
he  is  touched.  These  symptoms  are  followed  by  tenderness  and  retrac- 
tion of  the  postcervical  and  spinal  muscles  (opisthotonos),  extreme  nerv- 
ous irritability  and  muscular  tremor.  Delirium  quickly  develops,  and  in 
severe  cases  this  is  followed  by  stupor,  coma,  convulsions  and  death.  In 
the  milder  cases  the  same  symptoms  mark  the  onset,  but  the  subsequent 
course  of  the  disease  is  less  severe.  Fatal  cases  may  begin  with  compara- 
tively mild  symptoms,  and  cases  that  recover  may  have  a  violent  onset, 
but,  on  the  whole,  a  severe  initial  general  toxemia  is  commonly  followed 
by  a  severe  inflammation  of  the  brain  and  cord.  In  older  children  the  vio- 
lence of  the  onset  is  more  directly  in  proportion  to  the  severity  of  the  sub- 
sequent symptoms  than  it  is  in  infants,  to  whom  the  open  fontanels  furnish 
a  certain  degree  of  protection  from  the  early  pressure  symptoms  of  this 
disease. 

Vomiting,  which  is  commonly  the  initial  symj^tom,  is  projectile  in 
character  and  may  persist  for  a  number  of  days,  but  rarely  continues 
throughout  the  attack.     It  is  usually  associated  with  constipation. 

Nervous  Symptoms. — The  headache  which  is  an  early  symptom  is 
usualliy^  intense  and  is  usually  frontal,  but  may  involve  other  portions  of 
the  head  and  may  be  associated  with  restlessness,  irritability  and  photo- 


MENINGOCOCCUS    MENINGITIS  633 

phobia.  The  postcervical  and  spinal  muscles  become  tense  and  tender  and 
more  and  more  retracted  until  a  marked  opisthotonos  is  produced.  Irri- 
tation of  the  sensory  roots  of  the  spinal  nerves  produces  tenderness  on 
either  side  of  the  spine  and  a  more  or  less  general  hyperesthesia  of  the 
skin,  which  causes  the  patient  to  cry  out  with  pain  when  touched.  The 
irritation  of  the  motor  nerves,  which  produces  retraction  of  the  head  and 
backward  curvature  of  the  spine,  may  also  produce  a  tonic  contraction 
of  the  muscles  of  the  arms  or  legs,  resulting  in  the  drawing  up,  under  more 
or  less  tension,  of  these  extremities.  The  reflexes  associated  with  menin- 
geal irritation  are  well  marked.  Kernig's  sign  is  rarely  absent.  The 
Babinski  reflex,  which  is  of  little  value  in  children  under  two  years  of 
age,   can   usually  be  demonstrated,  and  the  tache  cerebrale  is   present. 


Fig.  95. — Opisthotonos  in  Cerebrospinal  Meningitis. 

These  reflexes,  while  of  importance  in  confirming  the  diagnosis  of  menin- 
gitis, are  of  little  value  in  differentiating  this  from  other  forms  of  menin- 
geal inflammation.  Delirium,  following  chilly  sensations,  is  an  early  and 
common  symptom;  in  the  milder  cases  it  may  quickly  subside,  and  the 
patient  may  remain  conscious  throughout  the  course  of  the  disease.  In 
the  more  severe  cases  the  delirium  may  become  so  violent  that  restraint 
is  necessary,  and  stupor  and  coma  may  supervene.  The  patient  may  come 
out  of  the  coma  to  again  become  actively  delirious,  and  this  delirium  may 
gradually  subside  as  convalescence  is  established.  A  prolonged  comatose 
condition  not  infrequently  occurs  in  fatal  cases. 

Fever. — With  the  onset  the  fever  rises  suddenly.  Within  the  first 
twenty-four  hours  it  may  reach  104°  or  105°F.  This  sudden  rise  in  the 
temperature,  accompanying  the  initial  symptoms  of  vomiting  and  head- 
ache, is  of  diagnostic  importance,  but  thereafter  the  temperature  curve  is 
of  little  diagnostic  or  prognostic  importance,  as  it  is  subject  to  such  varia- 
tions. After  the  initial  rise,  the  temperature  may  fall  almost  to  normal 
within  a  few  days.  Again  it  may  rise  to  104:°  or  105°F.,  and  its  subse- 
quent irregularities,  which  may  include  subnormal  temperatures,  followed 
by  high  fever,  give  little  information  as  to  the  progress  of  the  disease.  In 
prolonged  cases  the  temperature  may  continue  for  many  weeks  and  even 
months. 

The  fulse  in  children  is  rapid,  commonly  ranging  between  120  and 
160.  Respiration  is  accelerated;  as  the  disease  advances  it  may  become 
irregular,  and  Cheyne-Stokes  breathing  rarely  occurs. 


^J 


634 


MENINGITIS 


A  petechial  eruption  may  occur  as  dark-red  points  widely  disseminated 
over  the  skin  of  the  entire  body;  being  hemorrhagic  in  character,  it  does 
not  disappear  on  pressure.  It  may  be  preceded  or  followed  by  a  diffused 
mottling  of  the  skin  or  by  an  erythematous  rash.  Herpes  about  the  lips 
or  other  portions  of  the  face  may  occur.  Bed  sores  are  not  uncommon  in 
chronic  cases. 

Pronounced  nutritional  disturbances  occur  early  and  continue  through- 
out the  disease.  Emaciation  and  loss  of  strength  are  rapid  and  progres- 
sive. 

Blood  examinations  show  a  marked  polymorphonuclear  leukocytosis, 
which,  according  to  Huber,  varies  from  18,000  to  40,000. 

Differential  Diagnosis. — Lumbar  puncture  enables  us  to  make  an  accu- 
rate diagnosis  in  this  form  of  meningitis.     The  cerebrospinal  fluid  ob- 


DAY 
OF  MONTH 

31 

1 

2 

3 

4 

5 

G 

7 

8 

9 

10 

II 

12  1  13 

14  1   15  1 

DAY 
OF  DISEASE 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

II 

12 

13  >  14 

15 

I6| 

FAHRENHEIT   TEMPERATURE 

S 

1 

1 

h 

I 

/ 

I 

i 
1 

i 

1     I    :ll 

1±A      1 

/I 

1   •    i 

V  ; 

A      a' 

'    1 

j 

n 

1     ■     '  s 

\/     V 

/\  A  y^^     ^ 

J         1 

-• 

\ 

V  V 

ll 

1 

1 
1 

M 

i 

1 

PULSE 

o 

S 

s 

S 

s- 

5 

O 

o 

: 

S 

2 

!   :|:    I    ^    :    =  :l? 

11° 

"1    ^   i 

RESPIRATION 

s 

: 

s 

s 

s 

s 

8 

S 

S 

s 

S 

w 

J      •    1 

Pro.  96. — Meninqococcus  Meningitis  in  Child  Six  Yeaks  Old. 


tained  early  in  this  disease  always  contains  the  diplococcus  intracellularis, 
either  free  or  within  the  pohoiuclear  leukocytes  which  predominate  in  this 
fluid.  They  may  be  demonstrated  by  microscopical  examination  of  the 
sediment  obtained  by  centrifuging  the  fresh  cerebrospinal  fluid  or  by 
examining  cultures  inoculated  with  this  fluid.  The  finding  of  these  diplo- 
cocci  establishes  beyond  a  doubt  the  diagnosis  of  meningococcus  meningitis 
and,  if  the  technique  be  accurate,  the  failure  to  find  these  organisms  during 
the  first  week  precludes  this  diagnosis.  As  the  disease  progresses  the  find- 
ing of  diplococci  in  the  cerebrospinal  fluid  becomes  slightly  less  certain, 
so  that  after  the  first  week  a  number  of  negative  findings  is  necessary  to 


MENINGOCOCCUS    MENINGITIS  635 

justify  the  conclusion  that  the  disease  is  not  meningococcus  meningitis. 
It  is  quite  impossible  to  make  an  accurate  diflferential  diagnosis  between 
the  different  forms  of  meningitis  in  any  other  manner  than  by  a  careful 
examination  of  the  cerebrospinal  fluid,  and  yet  there  are  differences  in 
the  clinical  syndromes  of  the  most  common  forms  of  meningitis  which, 
when  carefully  studied,  may  materially  assist  in  making  the  differential 
diagnosis.  The  onset  in  tuberculous  meningitis  is  commonly  insidious, 
and  that  of  meningococcus  meningitis  is  sudden  and  tumultuous.  In 
meningococcus  meningitis  the  initial  high  fever,  the  pronounced  hyper- 
esthesia, the  high  leukocyte  count,  and  the  well-marked  retraction  of  the 
head  and  posterior  spinal  curvature  are  in  contrast  to  the  slight  fever,  the 
absence  of  hyperesthesia,  the  low  leukocyte  count,  the  slight  retraction  of 
the  head,  and  the  tuberculin  skin  reaction  which  are  commonly  present  in 
tuberculous  meningitis.  By  contrasting  these  symptom  groups  and  care- 
fully inquiring  into  the  previous  personal  and  family  history  of  the  pa- 
tient, and  by  further  considering  the  fact  that  in  the  absence  of  an  epi- 
demic of  meningococcus  meningitis,  the  tuberculous  is  much  the  most  com- 
mon form  of  this  disease,  one  can,  as  a  rule,  rather  definitely  differentiate 
the  tuberculous  from  the  meningococcus  type  (see  Tuberculous  Meningitis). 

Complications. — Conjunctivitis,  otitis,  and  pneumonia  are  the  most 
common  complications. 

Sequelae. — In  cases  not  treated  with  the  Flexner  serum  from  20  to  30 
per  cent,  of  those  that  recover  have  more  or  less  serious  sequelae.  The  most 
dreaded  after-effects  are  deafness  and  mental  deficiency.  Chronic  hydro- 
cephalus, blindness,  and  various  forms  of  paralysis  (cerebral,  spinal,  and 
peripheral)  may  also  result.  Under  the  influence  of  the  Flexner  serum,  in 
the  cases  that  recover,  the  cure  is  usually  complete ;  rarely,  permanent  deaf- 
ness may  result.  The  joint  affections,  which  sometimes  result,  can,  as  Ladd 
and  Netter  have  shown,  be  favorably  influenced  by  direct  injection  into  the 
inflamed  part,  of  the  antimeningitis  serum. 

Course  and  Duration. — Malignant  cases  may  run  a  very  rapid  course 
with  wild  delirium,  coma,  and  opisthotonos,  ending  fatally  in  a  few  days. 
In  the  great  majority,  however,  the  ordinary  course  of  the  disease  is  pro- 
tracted, lasting  for  weeks,  and  in  the  chronic  cases  for  months.  In  those 
cases  that  recover  convalescence  is  slow,  many  months  being  required  to 
restore  the  child  to  its  normal  condition.  Under  the  Flexner  serum  the 
course  of  the  disease  is  materially  modified,  its  duration  shortened,  and 
convalescence  is  much  more  rapid  and  complete.  In  these  cases  the  aver- 
age duration  is  now  believed  to  be  less  than  two  weeks.  A  marked  improve- 
ment in  the  patient's  general  condition  is  often  seen  within  twenty-four 
hours,  although  rigidity  of  the  neck  and  Kernig's  sign  may  persist  for  many 
days. 

Prognosis. — The  younger  the  child  the  greater  the  mortality.  Very 
young  infants  not  treated  with  the  Flexner  serum  rarely  recover.  Sporadic 
cases  are  commonly  milder  in  type  than  those  that  occur  during  epidemics. 
The  general  mortality  in  the  past  has  varied  from  70  to  85  per  cent.    The 


636  MENINGITIS 

indications  now  are  that  under  the  serum  treatment  this  mortality  will  be 
reduced  to  25  or  30  per  cent. 

Prophylaxis. — In  the  light  of  our  present  knowledge  of  the  etiology  of 
the  disease,  and  from  the  fact  that  a  number  of  persons  in  the  same  fam- 
ily are  not  infrequently  affected,  it  is  obligatory  for  the  physician  to  as- 
sume its  contagiousness.  The  sick  should  be  isolated  from  the  well  and 
all  catarrhal  discharges  from  the  throat  and  nose  of  the  patient  should 
be  disinfected.  The  cerebrospinal  fluid  drawn  by  lumbar  puncture  should 
be  80  handled  that  it  may  not  infect  the  surroundings  of  the  patient,  and 
all  individuals  coming  in  contact  with  the  sick  should  wash  their  throats 
and  nasal  passages  once  or  twice  a  day  with  an  alkaline  antiseptic  solution. 

Treatment. — Serum  Treatment. — The  antimeningitis  serum  developed 
by  Simon  Flexner  is  now  looked  upon  as  the  specific  treatment  for  this 
disease.  Its  use  has  been  followed  by  remarkably  curative  results.  It  is 
produced  in  the  horse  by  inoculation  of  the  animal  with  the  diplococcus 
intracellularis  and  its  products.  In  suspicious  cases  if  the  cerebrospinal 
fluid  is  cloudy,  the  serum  is  to  be  immediately  introduced  into  the  cerebro- 
spinal canal.  Subsequent  doses  are  to  be  given  if  the  diplococcus  intra- 
cellularis is  demonstrated  in  the  cerebrospinal  fluid,  or  if  the  first  dose  is 
followed  by  apparent  improvement  in  the  symptom  group. 

Technique  of  Administration. — The  serum  is  injected  into  the  spinal 
canal.  It  is  furnished  in  bottles  containing  15  c.  c.  and  is  stored  at 
refrigerator  temperature,  so  that  great  care  must  be  taken  to  have  the 
serum  warmed  to  body  temperature  before  it  is  injected.  Lumbar  punc- 
ture is  made  under  strict  aseptic  precautions,  and  all  of  the  cerebrospinal 
fluid  that  will  run  freely  is  carefully  collected  and  measured.  When  the 
flow  has  stopped,  a  syringe  containing  an  amount  of  serum  about  equal  to 
the  amount  of  cerebrospinal  fluid  that  has  escaped  is  attached  to  the  same 
needle,  and  through  it  the  contents  of  the  syringe  are  slowly  injected  into 
the  spinal  canal.  The  fluid  should  flow  from  the  syringe  without  resistance ; 
forcing  the  fluid  into  the  canal  under  pressure  is  fraught  with  danger. 

Dose. — The  average  initial  dose  is  30  to  40  c.  c.  In  very  severe  cases 
and  in  older  children  this  dose  may  be  increased  to  45  c.  c,  provided  this 
amount  of  serum  can  be  injected  without  undue  pressure;  occasionally 
a  quantity  of  serum  greater  than  the  amount  of  cerebrospinal  fluid  with- 
drawn may  be  injected  without  resistance.  It  is  commonly  necessary  to 
inject  30  c.  c.  of  the  serum  daily  for  four  or  five  days,  and  this  routine 
is  followed  in  the  treatment  of  the  average  case,  unless  the  symptoms 
quickly  disappear  under  the  treatment.  In  the  event  of  a  quick  response  to 
treatment  the  interval  between  the  injections  may  be  two  or  three  days,  and 
they  may  be  discontinued  when  convalescence  is  apparently  established  and 
the  diplococci  have  disappeared  from  the  cerebrospinal  fluid.  If  relapses 
occur  and  diplococci  reappear  in  the  cerebrospinal  fluid  of  cases  that  have 
been  apparently  convalescent,  the  serum  treatment  is  to  be  begun  again. 
The  number  of  doses  and  the  frequency  of  the  dose  can  be  determined 
only  by  the  manner  in  which  the  disease  responds  to  the  treatment.     As 


MENINGOCOCCUS    MENINGITIS  637 

long  as  symptoms  are  present,  and  diploeocci  are  found  in  the  spinal  fluid, 
the  serum  injections  are  to  be  continued  at  intervals  depending  upon  the 
severity  of  the  symptom  group. 

Results  Obtained.— Flexner  furnishes  the  following  table  of  cases  treated 
with  antimeningitis  serum : 

"Table  of  Cases  op  Epidemic  Cerebrospinal  Meningitis  Treated  with  the  Anti- 
meningitis  Serum. 

Cases  Analyzed  According  to  Age  Groups. 

Per  cent. 

Age  Years.                    Total  No.  Cases.  Eecovered.  Died.  Mortality. 

1-2      104  60  44  42.3 

2-5      112  82                           30  26.7 

5-10    113  95                            18  15.9 

10-15    101  78                           28  27.7 

15-20    107  72  35  32.7 

20+ 175  106  69  39.4 

Total,  all  ages 712  488  224  31.4 

"This  table  brings  out  several  points  of  interest.  The  highest  mortality 
is  shown  to  have  occurred  in  the  first  two  years  of  life.  But,  contrary  to  the 
rule  under  the  older  forms  of  treatment  in  which  the  mortality  was  90  per 
cent.,  or  over,  in  this  series  it  was  43.3  per  cent.  The  second  age  period  is 
from  2  to  5  years,  in  which  the  mortality  was  26.7  per  cent.  The  third  age 
period  embraces  children  from  5  to  10  years  of  age  and  gave  the  lowest 
mortality  of  all,  namely,  15.9  per  cent.  The  next  period  extends  from  10 
to  15  years  and  gave  a  mortality  of  27.7  per  cent.  The  next  period  of 
from  15  to  20  years  showed  a  considerable  rise  in  mortality,  equaling  32.7 
per  cent.,  and  the  last  period,  embracing  the  cases  of  20  years  and  over,  gave 
a  mortality  of  39.4  per  cent.  The  average  mortality  in  all  the  age  periods 
was  31.4  per  cent." 

The  following  table  from  the  same  source  shows  the  great  advantage 
to  be  obtained  by  the  early  use  of  the  serum  and  impresses  the  importance 
of  early  diagnosis  and  early  serum  treatment : 

Period  of   Injection   of  Serum.       Cases 

First   to   third   day    123 

Fourth  to  seventh  day 126 

Later  than  seventh  day  112 

The  specific  action  of  the  serum  is  also  shown  by  the  fact  that  in  25 
to  30  per  cent,  of  the  cases  treated,  the  disease  terminated  by  a  crisis  fol- 
lowing the  injection  of  the  serum. 

Mode  of  Action. — The  serum  is  bacteriolytic  and  but  feebly  antitoxic. 
It  acts  by  destroying  the  diplococcus.  This  diplococcus  furnishes  no  extra 
cellular  toxins.  Its  toxins  are  entirely  intracellular  and  are  liberated  only  by 
the  disintegration  of  the  diploeocci.    The  serum  not  only  destroys  the  diplo- 


Recovered 

Died 

Per 

Cent. 

107 

16 

16.5  " 

(( 

96 

30 

23.8  " 

<( 

73 

39 

35.     " 

(< 

638  MENINGITIS 

cocci  but  stimulates  phagocytosis  and  thereby  causes  the  dead  cocci  to  be 
quickly  swallowed  up  by  the  leukocytes,  wherein  their  intracellular  poison  is 
destroyed.  The  serum,  therefore,  acts  directly  by  destroying  the  diplococci 
and  indirectly  by  stimulating  the  leukocytes  to  destroy  their  toxins.  Under 
the  serum  treatment  the  turbidity  of  the  cerebrospinal  fluid  gradually  disap- 
pears, and  recovery,  when  it  occurs,  is  more  complete,  the  sequelae  in  these 
cases  being  comparatively  rare.  Deafness  occurred  in  a  few  instances,  and 
this  was  "the  only  persistent  defect  noted."  The  duration  of  the  disease  un- 
der the  serum  treatment  was  greatly  shortened.  The  average  duration  of  228 
cases  was  eleven  days. 

Symptomatic  Treatment. — The  pressure  symptoms  are  somewhat  re- 
lieved by  the  withdrawal  of  the  cerebrospinal  fluid;  for  this  reason  it  is 
important  to  allow  all  of  this  fluid  to  escape  that  will.  The  dietetic 
treatment  of  these  cases  is  most  important,  as  emaciation  and  loss  of 
strength  are  rapid.  Easily  digested  food  in  concentrated  form,  and  alcohol 
in  the  form  of  whiskey  or  brandy  well  diluted,  should  be  given;  in  young 
infants  the  nutritional  problem  is  very  difficult.  The  patient's  surround- 
ings should  be  as  quiet  as  possible,  and  the  room  darkened  so  that  he  may 
not  be  irritated  by  noise  and  light.  An  ice-bag  should  be  applied  to  the 
head  if  it  does  not  worry  the  patient.  Warm  baths  followed  by  gentle 
rubbing  of  the  skin  with  alcohol  may  be  of  service  in  promoting  the  periph- 
eral circulation  and  preventing  bedsores;  these  measures,  however,  can 
do  more  harm  than  good  during  the  stage  of  acute  hyperesthesia  of  the 
skin.  Chloral  and  veronal  may  be  used  to  produce  sleep.  In  the  iiiilder 
cases  the  bromids,  and  in  the  more  severe  cases  the  opiates,  may  be  called 
for.  Opium  should  not  be  used  unless  it  be  necessary,  but  the  severe  pains 
and  nervous  irritability  which  are  present  in  some  cases  may  demand  the 
hypodermic  use  of  morphin;  if  so,  the  initial  dose  should  be  small,  1/20 
to  1/50  of  a  grain,  and  gradually  increased,  if  necessary.  Tincture  of 
strophanthus  or  tincture  of  digitalis  may  be  used  to  stimulate  the  heart's 
action,  and  collapse  may  be  combated  by  the  subcutaneous  injection  of 
normal  salt  solution  or  camphor  dissolved  in  sterile  olive  oil.  During  the 
slow  convalescence  which  occurs  iodid  of  potassium  may  be  given.  Be- 
fore the  days  of  serum  treatment  this  drug  was  largely  used  and  was 
believed  to  exercise  a  favorable  influence  in  removing  inflammatory  exu- 
dates. 

PURULENT  MENINGITIS 

The  term  purulent  meningitis  is  used  to  include  all  forms  of  menin- 
gitis not  produced  by  the  tubercle  bacillus  or  the  diplococcus  intracellularis 
(meningococcus).  It  is,  therefore,  from  an  etiological  standpoint  not  a 
distinct  disease,  but  a  pathological  condition  which  may  be  caused  by  a 
number  of  pathogenic  microorganisms.  The  clinical  picture  produced  in 
these  cases,  regardless  of  the  specific  etiological  factor,  is  so  similar  that 
for  clinical  reasons  one  is  perhaps  justified  in  grouping  these  various  forms 
of  meningitis  under  the  same  clinical  heading.     The  term  "purulent," 


PURULENT    MEXIXGITIS  639 

however,  as  applied  to  this  group  of  cases  is  misleading,  in  that  it  implies 
that  tulxTculoiis  and  meningococcus  meningitis  are  not  purulent,  while  in 
both  of  these  forms  the  formation  of  pus  may  be  a  part  of  the  pathological 
process. 

The  most  common  causes  of  purulent  meningitis  are  the  pneumococcus, 
the  streptococcus  pyogenes,  the  bacillus  influenzae,  the  staphylococcus  pyo- 
genes, the  typhoid  bacillus  and  the  colon  bacillus.  Of  these  the  pneumo- 
coccus is  by  far  the  most  common. 

Symptomatology. — The  onset  and  general  symptomatology  of  purulent 
meningitis  more  closely  resemble  the  meningococcus  than  the  tuberculous 
form.  Its  symptoms  are  frequently  masked  by  the  primary  disease  of 
which  it  is  a  complication;  this  is  especially  true  when  it  is  secondary  to 
pneumonia,  erysipelas  and  septicemia.  In  these  conditions  a  meningitis 
involving  the  convexity  of  the  brain  may  develop  without  immediately 
adding  to  the  existing  symptom  group,  other  than  to  increase  the  delirium 
and  deepen  the  stupor  into  a  coma.  However,  in  the  great  majority  of 
cases  of  purulent  meningitis,  the  characteristic  symptoms  of  meningitis, 
as  previously  detailed,  are  sudden  in  onset  and  violent  in  character.  One 
usually  sees  a  sudden  rise  of  temperature,  projectile  vomiting,  marked  gen- 
eral irritation,  convulsions,  rigidity  and  retraction  of  the  neck,  photo- 
phobia, contracted  and  unequal  pupils,  rapid,  and  later  irregular,  pulse, 
irregular  and  sighing  respirations,  the  tache  cerebrale,  Kernig's  sign,  loss 
of  consciousness  and  profound  coma;  localized  convulsions  and  contrac- 
tures may  occur.  The  disease  in  the  great  majority  of  instances  ends 
fatally  within  a  week  or  ten  days  from  the  onset  of  the  initial  symptoms. 

Diagnosis. — The  differential  diagnosis  of  the  various  forms  of  purulent 
meningitis  can  be  made  only  by  a  careful  examination  of  the  cerebrospinal 
fluid  (see  Tuberculous  Meningitis).  A  careful  examination  of  this  fluid 
will  almost  invariably  reveal  the  exciting  cause,  and,  with  the  finding  of 
the  pneumococcus,  the  streptococcus,  the  bacillus  influenzae,  the  staphylo- 
coccus, the  typhoid  or  the  colon  bacillus,  the  differential  diagnosis  is 
definitely  made.  The  differentiation  of  purulent  meningitis  from  the  com- 
mon tuberculous  form  of  this  disease,  as  based  upon  the  clinical  syn- 
dromes produced,  has  already  been  noted  under  Tuberculous  Meningitis. 

Pneumococcus  meningitis  is  by  far  the  most  common  form  of  puru- 
lent meningitis  and  is  perhaps  always  associated  with  a  general  pneumo- 
coccic  infection,  the  pneumococci  being  present  in  the  blood  as  well  as  in 
the  cerebrospinal  fluid.  It  is  usually  associated  with  pneumonia  or  bron- 
chitis. It  is  sudden  in  its  onset,  and,  as  a  rule,  runs  a  short  and  violent 
course,  always  terminating  in  death.  The  duration  of  the  disease  is  com- 
monly from  three  to  eight  days. 

Streptococcus  and  staphylococcus  meningitis  may  be  rapid  or 
gradual  in  their  onset.  They  may  occur  as  complications  of  erysipelas,  sep- 
ticopyemia, middle-ear  disease,  mastoiditis,  and  fractures  of  the  bones  of 
the  skull,  as  a  complication  in  spina  bifida  and  as  a  mixed  infection  in 
tuberculous  meningitis.  These  cases  run  a  somewhat  less  violent  course 
43 


640 


MENINGITIS 


than  the  pneumococcic  cases;  the  streptococcus  form  always  terminates  in 
death;  tlie  staphylococcus  cases  show  a  slight  percentage  of  recoveries. 

Influenza  meningitis  is,  as  a  rule,  less  sudden  in  its  onset,  but  vio- 
lent and  characteristic  symptoms  of  meningitis  soon  develop,  and  the 
disease,  in  the  great  majority  of  cases,  ends  fatally.  The  percentage  of 
recoveries  here,  however,  is  greater  than  in  the  preceding  forms. 

Typhoid  meningitis  occurs  as  a  complication  of  typhoid  fever.  It 
is  commonly  fatal,  but  less  so  than  the  other  forms  of  purulent  meningitis. 

Treatment. — Antimeningitis  serum  is  of  absolutely  no  value  in  the  treat- 
ment of  the  forms  of  purulent  meningitis  above  noted.  In  these  cases, 
however,  it  is  impossible  to  make  a  differential  diagnosis  of  the  exact  type  of 


TIME 

i 

£ 

^ 

' 

< 

I 

X 

I 

J 

S 

* 

^■ 

^ 

^ 

i 

I 

I 

:H 

2    S   S 

< 

2 
< 

\ 

\ 

£ 

s 

I 

z 

^ 

s 

i 

z 

a.' 

f 

s 

s 

S 

* 

3 

J 

I 

^ 

^ 

J 

\ 

< 

< 

< 

i     1 

FAHRENHEIT   TEMPERATURE 

DETAILS                                                                                        CLINICAL 
OF  TREATMENT                                                                             MEMORANDA 

f\ 

l^ 

r 

« 

J 

f 

\ 

N 

r 

^ 

A 

1 

X 

* 

'V 

V' 

^ 

s. 

> 

\ 

/ 

r 

1 

/ 

f 

^ 

<y 

^ 

r 

r 

s 

f 

^ 

\ 

'    f 

/ 

^ 

\, 

/ 

/ 

/ 

V 

y' 

\ 

y 

\ 

V. 

V 

0 

DAY 
OF  DISEASE 

- 

« 

« 

« 

« 

CO 

'- 

oo 

PULSE 

II 

S| 

I  § 

=  2 

?? 

If 

II 

22 

S  S 

o  S  S  £ 

??:5 

g  £ 

?  5 

?  g 

?? 

11 

%,. 

-  ? 

S- 

.->. 

-- 

-.> 

^. 

.. 

-.. 

RESPIRATION 

£S 

S£ 

Sg 

2  S 

SS 

;s 

gg 

2  S 

;s 

s  s  s  s 

ss  SS 

ss 

5  S 

ss 

%% 

S  S 

SS 

ss 

lO    o 

ss 

ss 

ss 

;s 

J? 

2S 

Fig.  97. — Typical  Case  of  Pneumococcus  Meningitis;  Child  Ten  Years  of  Age. 


meningitis  until  a  careful  examination  of  the  cerebrospinal  fluid  has  been 
made.  As  this  examination  necessitates  the  loss  of  valuable  time,  and  as 
the  early  administration  of  the  antimeningitis  serum  is  of  so  much  im- 
portance in  the  meningococcic  cases,  it  is  perhaps  advisable  in  all  cases  of 
purulent  meningitis,  where  the  diagnosis  is  in  doubt,  to  inject  into  the 
spinal  canal  30  c.  c.  of  antimeningitis  serum  when  the  first  lumbar 
puncture  is  made.  If  the  examination  of  the  fluid  thus  withdrawn  shows 
the  disease  to  be  due  to  some  other  organism  than  the  diplococcus  intra- 
cellularis,  the  use  of  the  antimeningitis  serum  is  to  be  discontinued  and  the 
disease  is  to  be  treated  symptomatieally  as  outlined  under  Meningococcus 
Meningitis. 


ACUTE    ANTERIOR    POLIOMYELITIS  641 

Early  and  repeated  lumbar  puncture  is  advisable  in  all  forms  of  menin- 
gitis. It  relieves  the  pressure  symptoms,  and  perhaps  in  the  influenzal, 
typhoidal,  and  staphylococcus  forms  of  meningitis  it  may  increase  the  faint 
chances  of  recovery. 

Homologous  vaccines,  if  given  early,  may  be  of  value  and  should,  there- 
fore, always  be  used  in  the  staphylococcus  form. 

The  symptomatic  treatment  of  purulent  meningitis  should  include  ab- 
solute rest  and  quiet  in  a  well-ventilated  room,  careful  and,  if  necessary, 
forced  feeding,  cathartic  medication,  ice-bags  to  the  head,  chloral  and 
bromids  to  relieve  nervous  symptoms,  and  in  some  cases  small  doses  of 
morphin  hypodermically,  to  control  pain  and  convulsions.  If  the  inter- 
nal ear,  the  mastoid,  or  frontal  sinuses  are  infected,  surgical  interference 
may  be  resorted  to  to  drain  these  cavities,  but  it  is  questionable  whether 
surgical  measures  of  this  kind  are  ever  of  any  real  advantage  after  the 
symptoms  of  meningitis  have  appeared. 


CHAPTER   LXXX 
DISEASES    OP    THE    SPINAL    COED 

ACUTE  ANTERIOR  POLIOMYELITIS 

{Infantile   Spinal   Paralysis,  Polioencephalitis) 

Acute  anterior  poliomyelitis  is  an  acute  infectious,  slightly  contagious 
disease  occurring  both  epidemically  and  sporadically.  The  inflammatory 
lesions  begin  in  the  meninges  and  spread  to  the  cord,  involving  especially 
the  gray  matter  of  its  anterior  horns,  but  any  portion  of  the  central  nerv- 
ous system  may  be  involved.  The  symptom  group  produced  will  depend 
upon  the  extent  of  the  anatomical  lesions.  In  nearly  all  sporadic  cases, 
and  in  the  majority  of  cases  occurring  during  epidemics,  the  clinical 
picture  presented  depends  upon  the  involvement  of  the  anterior  horns  and 
adjacent  meninges  of  the  cord,  but  in  the  epidemic  form  many  cases  occur 
presenting  symptoms  of  acute  polioencephalitis,  bulbar  paralysis  or  menin- 
gitis. ^ 

Etiology. — The  course  and  onset  of  this  disease,  the  not  uncommon  oc- 
currence of  a  number  of  cases  in  the  same  family,  and  its  appearance  in 
epidemic  form  all  point  to  the  now  generally  accepted  conclusion  that  it 
is  caused  by  a  specific  microorganism,  but  as  yet  this  microorganism  has 
eluded  the  most  careful  search  of  bacteriologists.  Landsteiner  and  Popper 
transmitted  poliomyelitis  to  monkeys  by  inoculating  them  with  an  emulsion 
of  the  spinal  cord,  taken  from  a  child  just  after  death  from  this  disease. 
Flexner  and  Lewis  succeeded  in  carrying  the  strain  of  the  virus  thus  ob- 
tained through  many  generations  of  monkeys.  The  virus  is  not  destroyed 
by  glycerination,  will  pass  through  the  finest  filters,  is  injured  by  heat, 
45°  to  50°C.,  but  is  not  destroyed  by  drying  or  by  cold;  it  "belongs  to  the 


642  DISEASES   OF   THE   SPINAL   COED 

class  of  minute  and  filterable  viruses  that  have  not  thus  far  been  demon- 
strated under  the  microscope."  The  disease  may  also  be  transmitted  by 
the  brain  substance,  lymph  nodes,  salivary  glands,  tonsils,  mucous  membrane 
of  the  nasopharynx,  and  by  the  blood  and  cerebrospinal  fluid  of  monkeys  ill 
of  this  disease.  The  experiments  of  many  observers  have  demonstrated  that 
the  virus  from  the  above-named  sources  will  produce  the  disease  in  monkeys 
when  injected  into  the  brain,  the  spinal  cord,  the  tissues  adjacent  to  periph- 
eral nerves,  the  blood  stream,  and  the  anterior  chamber  of  the  eye,  and 
also  by  rubbing  the  virus  into  the  mucous  membrane  of  the  nasopharynx 
or  introducing  it  into  the  stomach  or  intestines.  These  experiments  sug- 
gest that  infection  in  human  beings  may  occur  through  the  nasopharynx 
or  gastrointestinal  canal.  The  manner  in  which  the  virus  may  be  trans- 
mitted from  one  individual  to  another  is  not  known.  In  its  epidemic  form 
the  disease  extends  through  low-lying,  well-watered  areas  and  along  routes 
of  travel.  It  may  be  spread  by  abortive  ambulant  cases,  by  healthy  interme- 
diate carriers,  by  animals  having  the  disease,  and  perhaps  by  insects  such 
as  the  common  house-fly,  and  by  fomites  such  as  dust. 

Acute  anterior  poliomyelitis  may  occur  sporadically  or  in  epidemic 
form.  The  most  notable  epidemic  in  this  country  occurred  in  Xew  York 
City  and  its  surroundings  in  1907;  it  included  2,500  cases.  Holt  and 
Bartlett  made  a  very  complete  report  on  the  "Epidemiology  of  Acute  Polio- 
myelitis," which  included  an  analysis  of  thirty-five  epidemics.  They  found 
"many  instances  of  closely  connected  groups  of  cases.  In  one  instance 
there  were  seven  in  one  family;  in  three  instances  four  in  a  family;  five 
instances  of  three  in  a  family,  and  in  all  forty  instances,  comprising  69 
cases  of  more  than  one  in  a  family."  The  startling  increase  in  the  epi- 
demic form  of  this  disease  is  shown  in  Lovett's  compilation  of  the  reported 
epidemics  since  1881 : 

Average 
Years.  Cases.        Outbreaks. -kj      i,       -,  /^ 

Number  of  Cases. 

1880-1884  23  2                     11.5 

1885-1889 93  7                     13 

1890-1894  151  4  38 

1895-1899  345  23                     15 

1900-1904  349  9                     39 

1905-1909  8,054  25  322 

The  sporadic  form  of  this  disease  i-s  rare  during  the  first  few  months 
of  life,  but  in  the  latter  half  of  the  first  year  it  is  quite  common ;  the  sec- 
ond year  of  life  is  the  period  of  greatest  susceptibility,  and  in  the  third 
year  it  is  still  quite  frequent,  but  after  the  fifth  year  it  is  comparatively 
rare;  about  50  per  cent,  occur  during  the  first  and  second  years,  and  80 
per  cent,  during  the  first  three  years. 

The  epidemic  form  occurs  with  almost  equal  frequency  in  young  child- 
hood as  in  infancy;  it  is  very  common  between  the  ages  of  four  and  thir- 
teen, and  not  uncommon  in  early  adult  life.  This  form  is  also  slightly 
transmissible  by  direct  contact;  the  degree  of  contagiousness  is  not  very 


ACUTE    ANTERIOR    POLIOMYELITIS  643 

great,  since  only  a  small  proportion  of  exposed  individuals  contract  the 
disease.  It  occurs  with  slightly  greater  frequency  in  boys  than  in  girls. 
Dry,  warm  weather  very  materially  influences  its  spread.  Fifty  per  cent, 
of  the  cases  occur  during  the  dry  hot  months  of  August  and  September, 
and  70  or  80  per  cent,  between  the  first  of  June  and  the  first  of  October. 
Epidemics  occur  almost  invariably  during  the  warm,  dry  months,  and  are 
usually  terminated  by  cold  weather;  occasionally,  however,  an  epidemic 
is  continued  with  sporadic  outbreaks  after  cold  weather  has  begun. 

Pathology. — Acute  anterior  poliomyelitis  is  a  general  infection  produc- 
ing especially  an  interstitial  inflammation  characterized  by  congestion, 
perivascular  round-celled  infiltration  and  edema  of  the  leptomeninges,  the 
spinal  cord  and  brain.  Inflammatory  changes  occur  first  in  the  pia  mater 
of  the  cord  and  the  medulla,  and  are  most  marked  around  the  blood  vessels ; 
about  these  the  round-celled  infiltration  is  greatest  and  may  contract  their 
lumen,  producing  congestion,  edema  and  minute  hemorrhages. 

The  cerebrospinal  fluid  is  increased  in  quantity  and  quite  early  in  the 
disease  is  opalescent,  due  chiefly  to  an  increase  in  the  number  of  lympho- 
cytes, although  polymorphonuclear  leukocytes  may  also  be  present.  By 
the  third  or  fourth  day  the  cerebrospinal  fluid  is  clear,  but  is  still  in- 
creased in  quantity,  and  contains  a  large  number  of  lymphocytes. 

All  of  the  blood  vessels  of  the  cord  coming  from  the  inflamed  pia  are 
congested  and  show  perivascular  round-celled  infiltration,  and  there  results 
a  more  or  less  general  myelitis,  more  marked  in  the  gray  matter  of  the 
anterior  horns  and  commonly  most  severe  in  the  cervical  and  lumbar  en- 
largements than  in  other  segments  of  the  cord.  This  inflammation  in 
the  cord,  like  that  in  the  meninges,  is  marked  by  congestion,  round-celled 
infiltration,  edema  and  minute  hemorrhages,  and  results  in  extensive  dam- 
age to  nerve  cells,  especially  the  motor  nerve  cells  in  the  anterior  cornua. 
Ganglion  cells,  however,  in  the  posterior  horns,  especially  in  Clark's  col- 
umn, are  not  uncommonly  affected.  The  degenerative  changes  in  the 
nerve  cells  may  result  in  their  complete  destruction,  and  a  permanent  mo- 
tor paralysis  and  atrophy  of  the  muscles  supplied  by  the  axons  coming 
from  these  cells.  Edema,  or  temporary  alteration  leading  to  functional 
impairment,  but  stopping  short  of  permanent  degeneration  of  the  ganglion 
cells,  may  cause  a  transient  paralysis  of  the  muscles  innervated  by  their 
neurons.  The  predominance  of  these  lesser  lesions  explains  the  fact  that 
the  greater  part  of  the  widespread  paralysis  occurring  during  acute  an- 
terior poliomyelitis  is  transient,  and  also  explains  the  hopeless  character 
of  the  final  permanent  paralysis  of  an  associated  muscle  group. 

It  is  important  to  remember  that  inflammatory  lesions  may  also  occur 
in  the  white  matter  of  the  cord,  thereby  implicating  the  long  ascending 
and  descending  tracts,  thus  explaining  such  rare  lasting  motor  disturb- 
ances as  ataxia,  exaggerated  reflexes  and  muscular  spasticity.  Inflam- 
matory changes  in  the  spinal  ganglia,  the  medulla  oblongata  and  pons 
varolii,  similar  to  those  above  noted  in  the  cord,  may  occur,  and  infiltra- 
tion around  the  deep  nuclei  of  cranial  nerves  explains  the  facial  and  other 


644  DISEASES   OF   THE    SPINAL   CORD 

paralyses  of  these  nerves.  Like  changes  may  occur  in  the  cerebellum 
and  less  rarely  in  the  cere])ral  cortex.  In  fatal  cases  not  only  the  pi  a 
mater  and  the  spinal  cord,  but  the  medulla,  pons,  basal  ganglia  and  even 
the  cerebrum  may  be  involved  in  the  inflammation.  In  mild  cases,  espe- 
cially of  the  sporadic  type,  the  inflammatory  changes  are  almost  or  quite 
limited  to  the  anterior  half  of  the  cord,  and  the  paralysis  which  accom- 
panies and  follows  this  condition  is  largely  due  to  degenerative  changes  in 
the  anterior  horn  cells  of  its  cervical  and  lumbar  enlargements. 

Chronic  Changes. — As  time  goes  on  many  of  the  injured  ganglion 
cells  entirely  recover,  others  are  destroyed,  and  the  axons  emanating  from 
them  disappear.  The  destruction  of  the  nerve  roots  makes  the  anterior 
nerve  root  bundles  smaller  and  produces  an  atrophy  of  the  muscles,  while 
the  absence  of  the  trophic  influence  of  the  anterior  cornual  cells  is  shown 
by  more  or  less  lack  of  development  of  that  part  of  the  body  supplied  by 
the  diseased  nerve  cells.  In  such  cases  also  the  affected  part  of  the  cord 
is  diminished  in  size  and  sclerotic  changes  occur. 

Lesions  are  found  outside  of  the  nervous  system,  but  they  are  not 
characteristic.  Bronchopneumonia  and  parenchymatous  degeneration 
of  the  liver  and  kidneys  occur.  Changes  in  the  mucous  membrane 
of  the  small  intestine  and  stomach  are  common;  congestion  and  enlarge- 
ment of  the  solitary  follicles,  Peyer's  patches  and  mesentery  glands  are 
common. 

Immunity. — One  attack  is  believed  to  confer  immunity. 

Symptomatology. — Wickman  has  described  eight  distinct  types  of  acute 
anterior  poliomyelitis,  namely:  the  spinal  poliomyelitic ;  the  abortive;  the 
ascending  or  descending;  the  bulbar  or  pontine;  the  encephalitic ;  the 
ataxic;  the  polyneuritic,  and  the  meningeal. 

Spinal  Poliomyelitic  Type. — This  is  the  ordinary  form.  Its  onset 
is  marked  by  nervous  irritability,  restlessness,  headache,  pain  in  the  spine 
and  extremities,  fever,  sweating,  marked  prostration,  and  gastrointestinal 
disturbances.  Vomiting  is  common,  diarrhea  is  present  in  about  one-half 
the  cases,  and  constipation  in  the  remainder.  Tonsillitis  may  also  occur 
as  an  initial  symptom.  The  fever  in  mild  cases  varies  from  100°  to 
101°F. ;  in  severe  cases  it  may  reach  105°F.  It  occurs  as  an  early  symp- 
tom and  continues  in  mild  cases  for  one  or  two  days,  and  in  severe  cases 
for  a  week.  Hyperesthesia  is  present,  and  movement  of  the  body,  especially 
the  head,  produces  pain.  The  pain,  tenderness,  and  rigidity  of  the  muscles 
of  the  neck  and  spine  are  early  and  characteristic  symptoms,  usually  asso- 
ciated with  a  slight  retraction  of  the  head.  The  mind  is  usually  clear, 
but  apathy  and  drowsiness  may  occur;  very  rarely  delirium,  convulsions, 
and  coma  are  seen.  Early,  the  deep  reflexes  are  frequently  exaggerated, 
but  later  they  are  diminished  and  vasomotor  disturbances  are  very  com- 
mon. Paresthesia  or  numbness  may  precede  or  accompany  the  beginning 
paralysis.  Meningitic  symptoms  are  present  in  some  cases;  with  the  pain, 
stiffness,  and  tenderness  of  the  neck  and  spine  there  may  be  a  marked  re- 
traction of  the  head,  intense  nervous  excitability,  photophobia  and  a  mod- 


ACUTE    ANTERIOR    POLIOMYELITIS  645 

ified  Kernig's  sign.  The  spleen  is  enlarged  and  leukopenia  with  a  rela- 
tive increase  of  lymphocytes  occurs  early. 

The  clinical  syndrome  made  up  in  whole  or  part  of  the  symptoms 
above  noted  may  continue  for  four  or  five  days,  and  then  gradually  sub- 
side, and  during  this  time  the  characteristic  paralysis  makes  its  appear- 
ance. With  the  onset  of  this  paralysis  the  pain,  tenderness,  and  hyper- 
esthesia previously  noted  are  increased  in  the  paralyzed  part,  and,  rarely, 
a  marked  line  of  tenderness  may  be  noted  along  the  peripheral  nerves. 
In  some  cases,  especially  the  sporadic  ones,  the  fever  and  acute  symptoms 
above  detailed  may  be  slight  or  absent,  and  the  typical  paralysis  may  de- 
velop with  a  few  accompanying  symptoms ;  such  cases  are  usually  mild,  and 
the  paralysis  is  not  widely  distributed. 

Abortive  Type. — During  epidemics  it  is  estimated  by  various  observ- 
ers that  from  15  to  50  per  cent,  of  all  cases  belong  to  the  so-called  abor- 
tive type.  They  present  a  syndrome  which  commonly  includes  the  follow- 
ing symptoms:  fever,  headache,  nausea,  vomiting,  diarrhea,  constipation, 
nervous  irritability,  pain  in  the  neck,  back  and  limbs,  ataxia,  diplopia,  and 
exaggerated  or  diminished  patellar  reflex,  but  which  may  include  any  of 
the  above-named  symptoms  associated  with  the  ordinary  form  of  this  dis- 
ease. This  symptom  group,  however,  subsides  into  convalescence  without 
a  supervening  paralysis,  but  these  cases  usually  show  extreme  weariness  and 
muscular  weakness.  Their  diagnosis  largely  depends  upon  the  fact  that 
they  occur  during  epidemics  of  acute  anterior  poliomyelitis  and  resemble 
in  their  onset,  and  in  many  of  their  symptoms,  other  cases  of  this  disease 
having  the  supervening  paralysis.  The  immune  bodies  which  are  present 
in  the  blood  of  patients  recently  recovered  from  frank  attacks  of  this 
disease  can  also  be  demonstrated  in  the  blood  of  these  abortive  cases  by 
the  fact  that  they  render  inactive  the  specific  virus  of  this  disease. 

The  x\scending  or  Descending  Type. — The  clinical  course  of  this 
type  is  identical  with  that  of  so-called  Landry's  paralysis.  It  may  appear 
first  in  the  lower  or  upper  extremities  or  in  the  muscles  supplied  by  the 
cranial  nerves;  it  then  descends  or  ascends.  The  ascending  type  is  more 
common;  it  begins  in  the  legs  and  may  involve  almost  the  entire  body. 
As  it  progresses  upward  the  muscles  of  the  legs,  abdomen,  back,  chest,  arms, 
neck  and  diaphragm  may  be  involved,  and  death  commonly  ensues  from 
paralysis  of  the  external  muscles  of  respiration  or  from  phrenic  paralysis 
within  from  one  to  three  days.  This  form  must  not  be  confused  with  that 
in  which  death  results  from  paralysis  of  the  centers  of  respiration. 

Bulbar  or  Pontine  Type. — During  epidemics,  eases  not  infrequently 
occur  in  which  the  severe  constitutional  symptoms  of  acute  polioencephalitis 
are  associated  with  paralysis  of  the  cranial  nerves  whose  nuclei  are  situ- 
ated in  the  medulla  oblongata  and  pons  cerebri.  The  paralysis  of  these 
nerves  may  or  may  not  be  associated  with  paralysis  of  the  trunk,  neck  or 
extremities.  The  facial  paralysis  in  these  cases  is  commonly  unilateral 
and  usually  associated  with  an  oculomotor  paralysis,  causing  divergent 
squint  with  or  without  ptosis.     Disturbances  of  deglutition,  dyspnea,  and 


646 


DISEASES    OF    THE    SPINAL   COED 


irregular  respiratory  action,  with  a  rapid  and  irregular  pulse,  are  common 
symptoms.  The  bulbopontine  paralysis  occurring  in  these  cases  may  almost 
or  quite  disappear,  leaving  perhaps  a  slight  facial  or  oculomotor  paralysis. 
In  severe  cases  obstinate  constipation  and  retention  of  urine  may  occur, 
and  death  may  result  from  splanchnic,  cardiac,  or  respiratory  paralysis. 

The  Encephalitic  Type. — This  is  characterized  by  symptoms  re- 
sembling meningitis,  and  is  associated  with  paralyses  due  to  lesions  in  the 
motor  areas  of  the  brain,  such  as  spastic  monoplegia  or  hemiplegia,  or  to 
paralyses  of  the  bulbar  or  pontine  type. 

The  Ataxic  Type. — This  is  a  polioencephalitis  involving  also  the 
cerebellum.  The  symptoms,  as  in  the  encephalitic  form,  are  very  acute 
and  violent,  but  the  meningeal  symptoms  are  associated  with  ataxia  of 


a  3  a  aji  a'a  a' s  a'a'a  i'a  3  aji  33  3  s  a  a  a' ii'a  3  a  s  as  a  i  a  aa  s  aa  as  3  a  a  s  a]a  a  s  a  a  a  s  3  a  a  i  s  i  s  i  f  i  1 5 

107' 

,,R,           J 

"       .              k\ '  /  %,.^ 

%      <           /    ^^^'i       "^^J^^ 

a       '"3  ■" ■■;* S'    ' " 

s                         /j                                v. 

^           ,02   --------j^                                                           ^- 

t    ,o,..^ji|r:: . 55i;:5 

S          lOO                     ■  ■                                                                                  ^^i'         .■',.- J,  > 

<            90 ^/^ 

X  ^\  1 

Fig.  98. — Acute  Anterior  Poliomyelitis  of  the  Bulbar  or  Pontine  Type. 

In  this  case  four  doses  of  16  ounces  of  normal  salt  solution,  each  containing  10  grains  of 
urotropin,  were  given  on  the  third  and  fourth  day.  After  this  treatment  the  child 
made  a  slow  and  complete  recovery. 

movement  of  the  arms  and  legs,  nystagmus,  and  explosive  syllabic  speech; 
this  form  is  very  rare. 

The  Polyneuritic  Type. — In  this  type  the  peripheral  nerves  are  in- 
volved, presenting  a  picture  somewhat  resembling  multiple  neuritis.  It  is 
not  uncommonly  associated  with  the  ordinary  spinal  poliomyelitic  type. 
Pain  is  the  prominent  symptom;  it  may  be  commonly  elicited  by  pressure 
over  the  nerve  trunks  or  joints  of  the  paralyzed  parts.  In  some  cases  the 
pain  and  tenderness  are  very  marked  in  only  slightly  paralyzed  parts,  so  that 
early  in  the  disease  the  paralysis  may  be  overlooked  and  a  diagnosis  of 
rheumatism  or  scurvy  made.  In  other  cases  there  may  be  a  combination 
of  flaccidity  and  spasticity,  the  latter  resulting  in  contractures  which  may 
cause  errors  in  diagnosis. 

The  Meningeal  Type. — This  is  an  indistinct  type,  probably  covered  by 


ACUTE    ANTERIOR    POLIOMYELITIS 


647 


the  encephalitic  type  above  noted.    It  presents  the  symptoms  of  meningitis 
associated  with  paralyses  of  various  kinds. 

Paralysis. — This  is  the  characteristic  symptom  which  confirms  the 
diagnosis.  During  epidemics  it  may  occur  within  the  first  twenty-four 
hours;  in  the  sporadic  form  it  is  not,  as  a  rule,  recognized  until  much 
later,  but  in  all  cases,  except  those  of  the  abortive  type,  it  becomes  so  evi- 
dent between  the  second  and  the  fifth  day  that  it  can  scarcely  be  over- 
looked, even  though  it  be  overshadowed  by  violent  acute  symptoms.  Ander- 
son &  Frost  say:  "Cases  of  acute  anterior  poliomyelitis  are  encountered 
showing  all  gradations  in  the  degree  and  extent  of  paralysis.  In  the  same 
group  may  be  found  cases  resulting 
in  extensive  and  lasting  paralysis; 
cases  with  permanent  paralysis  of 
slight  extent ;  cases  in  which  the  pa- 
tients have  transient  paralysis,  re- 
covering completely  within  a  few 
weeks  or  even  a  few  days;  other 
cases  in  which  there  is  no  definite 
paralysis,  but  merely  muscular 
weakness  of  short  duration;  still 
others  in  which  the  only  motor  dis- 
turbance is  ataxia,  tremor  or  a  tran- 
sient ocular  disturbance,  such  as 
diplopia  or  nystagmus.  Finally, 
within  the  same  group  are  seen  cases 
of  illness  exhibiting  only  the  symp- 
toms of  a  general  infection,  usually 
accompanied  by  symptoms  indicative 
of  meningeal,  spinal  or  encephalitic 
irritation,  but  without  definite  mo- 
tor disturbances."  In  the  majority 
of  instances  the  paralysis  is  motor 
and  is  complete  and  flaccid  in  char- 
acter; the  part  involved  offers  no 
resistance  and  falls  limply  into  the 
position  gravity  directs.     It  reaches 

its  maximum  in  from  one  to  three  days  after  its  onset  and  involves  the  mus- 
cles of  one  or  more  limbs,  and,  more  rarely,  the  muscles  of  the  trunk, 
neck  and  face.  After  a  period  of  one  or  two  weeks  the  paralysis  be- 
gins to  subside  and  the  patient  commences  to  regain  motion  in  the 
paralyzed  part.  This  improvement  may  continue  rather  rapidly  for 
four  or  five  weeks,  leaving,  in  90  per  cent,  of  the  cases,  a  group  of 
muscles  functionally  related,  still  paralyzed.  The  extent  of  the  re- 
maining paralysis  represents  the  actual  damage  to  the  part  involved  and 
indicates  the  location  and  extent  of  the  injury  to  the  motor  cells  of  the 
anterior  horn  or  similar  cells  in  the  upper-lying  parts  of  the  nervous 


Fig.  99. — The  Two  Commonest  Varieties 
OF  Foot  Deformity  from  Anterior 
Poliomyelitis,  in  the  Same  Patient. 

In  the  right  foot,  equino-varus  from  paraly- 
sis of  the  peroneal  group;  in  the  left 
foot,  valgus  from  paralysis  of  tibialis 
anticus  and  posticus.     (A.  Freiberg.) 


648 


DISEASES   OF   THE   SPINAL   CORD 


system.  After  the  third  or  fourth  month  the  amount  of  improvement  which 
occurs  in  the  paralyzed  member  depends  largely  upon  the  treatment  in- 
stituted, but,  for  the  most  part,  the  muscular  paralysis  then  existing  is 
permanent.  In  the  great  majority  of  cases  the  paralysis  is  confined  to 
the  lower  extremities,  and,  as  a  rule,  only  one  leg  is  involved.  When  the 
upper  extremities  are  involved  the  paralysis  is  usually  general,  both  arms 
and  legs  being  affected,  and  the  trunk  and  face  muscles  may  also  be  in- 
volved. Less  commonly  one  upper  extremity  is  involved  with  one  lower, 
usually  on  opposite  sides,  and  still  less  frequently  one  upper  and  both  lower 

extremities,  and  very 
rarely  one  upper  ex- 
tremity alone  is  par- 
alyzed. 

In  the  rare  cases, 
where  the  cerebrum 
as  well  as  the  spinal 
cord  is  involved,  we 
may  have  a  combina- 
tion of  flaccid  and 
spastic  paralysis. 

Muscular  atro- 
phy is  one  of  the 
most  notable  features 
of  this  disease.  Atro- 
phy and  fatty  degen- 
eration of  the  par- 
alyzed muscles  and 
their  tendons  quick- 
ly begin,  and  become 
very  marked  after  a 
few  weeks.  The  wast- 
ing of  muscles  very 
materially  re- 
duces the  size  of  the 
affected  limb.  -In  ex- 
treme cases  the  cir- 
cumference of  the  part  may  be  reduced  to  almost  half  its  original  size ;  this 
may  in  part  be  due  to  the  loss  of  subcutaneous  fat.  The  growth 
of  the  paralyzed  limb  is  diminished  so  that  in  time  it  may  be  much 
shorter  than  its  fellow.  In  severe  cases  the  wasted,  dwarfed  and 
withered  extremity  is  loose-jointed  and  markedly  deformed.  These  de- 
formities result  largely  from  the  action  of  the  normal  muscles  of  the 
part,  the  antagonistic  muscles  being  paralyzed.  The  foot,  leg,  hand,  arm, 
and  spine  may  thus  be  drawn  into  abnormal  positions,  resulting  in  various 
forms  of  clubfoot,  clubhand,  curvature  of  the  spine  and  subluxation  .of 
joints,  especially  the  shoulder  and  knee.    The  skin  of  the  paralyzed  part  is 


FlO.    100. QUADBUPEDAL    GaIT    IN  A  BoY  OF  TeN  YeABS  RE- 
SULTING   FBOH    ANTEBIOB    POLIOMYELITIS. 

There  was  marked  flexion  contracture  of  the  right  hip  and 
paralysis  of  the  quardriceps  extensor  and  sartorius  of  the 
right  thigh.  Extensive  paralysis  of  leg  muscles  on  lx)th 
sides.  Boy  enabled  to  walk  erect  without  crutches  by 
means  of  tenotomies  and  tendon  transplantation.  (A. 
Freiberg.) 


ACUTE    ANTERIOR    POLIOMYELITIS  649 

notably  reduced  in  temperature,  it  appears  dry,  shriveled,  and  at  times 
cyanosed,  and  is  cold  and  lifeless  to  the  touch.  A  further  evidence  of  the 
loss  of  the  trophic  influence  of  the  anterior  cornual  cells  is  the  great  re- 
duction in  the  size  of  the  bones  of  the  affected  extremities,  as  can  be  clearly 
shown  by  skiagraphs. 

The  CHANGED  ELECTRICAL  REACTIONS  of  the  paralyzed  muscles  may  be 
a  very  important  diagnostic  sign.  Tliey  fail  to  respond  to  the  faradic 
current,  and,  as  the  atrophy  progresses,  they  show  the  reactions  of  de- 
generation to  the  galvanic  current;  that  is  to  say,  they  respond  feebly  and 
slowly,  and  the  anodal  closure  contraction  exceeds  the  cathodal  closure  con- 
traction, and  after  a  time  they  fail  entirely  to  respond  to  any  form  of  elec- 
trical stimulation. 

The  reflexes  in  the  paralyzed  part  are  nearly  always  absent.  The  knee- 
jerk,  however,  may  be  present  where  the  disease  of  the  cord  is  confined 
to  the  cervical  or  lower  dorsal  region,  and  it  may  also  be  present  in  those 
cases  seen  during  epidemics  where  the  disease  is  confined  to  other  portions 
of  the  central  nervous  system  than  the  cord. 

Diagnosis The  early  stage  of  acute  anterior  poliomyelitis  so  closely 

resembles  that  of  other  acute  infections  that  it  may  be  impossible  to  make 
a  diagnosis  until  the  paralysis  is  discovered.  During  an  epidemic,  how- 
ever, the  physician  should  at  least  make  a  provisional  diagnosis  in  the 
presence  of  the  symptom  groups  which  ordinarily  announce  the  onset  of 
this  disease.  It  may  be  mistaken  for  acute  intestinal  infection  or  influ- 
enza, because  of  the  presence  of  fever,  vomiting,  and  nervous  symptoms, 
but  these  disorders  should  soon  be  excluded  by  the  subsequent  course  of 
the  disease.  When  announced  with  high  fever,  general  hyperesthesia, 
convulsions,  and  stupor,  it  may  be  mistaken  for  some  form  of  meningitis; 
in  such  cases  lumbar  puncture  may  materially  assist  in  clearing  the  diag- 
nosis, since  a  bacteriological  examination  of  the  cerebrospinal  fluid  fails  to 
reveal  the  presence  of  microorganisms,  but  shows  a  largo  number  of  polynu- 
clear  or  mononuclear  cells.  In  the  early  stages  the  blood  may  show  a 
leukopenia  and  a  moderate  lymphocytosis,  and  Gay  and  Lucas  note  that  the 
differential  coimt  shows  a  relative  increase  in  the  number  of  oosinophiles. 

With  the  onset  of  the  paralysis  there  should  be  little  difficulty  in 
making  a  diagnosis  if  the  following  points  pertaining  to  the  differential 
diagno'sis  of  tlie  common  paralyses  of  infancy,  viz.,  infantile  paralysis, 
cerebral  palsy,  and  multiple  neuritis,  are  kept  in  mind : 

Acute  Anterior  Poliomy-  Cerebral  Palsy  Multiple  Neuritis 

ELITIS 

Occurs  most  commonly  dur-     Occurs      most      commonly  More     common     in     child- 

ing  second  year.  during  first  year.  hood  and  adult  life. 

Occurs     sporadically     and     Usually    due    to    cerebral  Follows   diphthena,    rarely 

epidemically     without     ap-     hemorrhage    or    congenital  produced   by   other   causes 

parent  cause.  ^^fects,     parturient     inju-  in  childhood. 

ries. 


f)50 


DISEASES  or  THE  SPINAL  COED 


ActJTE  Anterior  Poliomy- 
elitis 
Convulsions,  not  commonly 
repeated,  occur  in  10  to  15 
per  cent,  of  the  cases. 
Paralysis  (motor)  com- 
plete, flaccid.  Limb  limp 
and  non-resistant. 


Paralysis  commonly  con- 
fined to  one  or  both  legs. 
Arms,  trunk  and  back  may 
be  involved. 

Muscles  atrophied  and  de- 
generated after  a  few 
weeks. 

Limbs  shorter  from  lack 
of  growth,  a  late  symptom. 
Electrical  reactions,  al- 
tered and  lost. 

Knee-jerk  commonly  lost. 

Intellect  not  involved. 


Cerebral  Palsy 

Repeated  convulsions  in 
most  cases;  frequently  a 
causative  factor. 
Paralysis  (motor)  partial, 
spastic.  Limb  rigid,  con- 
tractures present. 


P  a  ra  1  y  s  i  s,  hemiplegic ; 
other  forms  such  as  diple- 
gia, paraplegia  and  mono- 
plegia comparatively  rare. 
Muscles  not  atrophied. 


Lack  of  development,  not 
so  marked. 

Electrical  reactions,  nor- 
mal. 

Knee-jerk  increased.  Ba- 
binski  sign,  perhaps  clonus. 
Lack  of  mental  develop- 
ment. Epilepsy  may  result. 


Multiple  Neuritis 
No   convulsions. 


Paralysis  (both  motor  and 
sensory)  complete,  flaccid. 
Limb  limp,  and  may  be 
acutely  sensitive  along  the 
line  of  the  nerve. 
Paralysis,  paraplegic,  or 
limited  to  the  distribution 
of  the  nerves  involved. 

Muscles  slightly  atrophied, 
but  recover. 

No   shortening. 

Electrical      reactions,      al- 

t  e  r  e  d     and     diminished, 

sometimes    lost. 

General  loss  of  reflexes  in 

part   involved. 

Central  nervous  system  in 

no  way  involved. 


Progfnosis. — Holt  and  Bartlett  found  in  the  epidemic  form  of  this  dis- 
ease a  mortality  of  12  per  cent,  in  1,659  cases.  Wickman  found  the  death 
rate  under  eleven  years  of  age  to  be  12.2  per  cent.,  and  from  twelve  to 
thirty-two  years  of  age  27.9  per  cent.  The  Massachusetts  State  Board  of 
Health  found  the  mortality  to  be  16  per  cent,  in  infants  under  one  year; 
4  per  cent,  from  one  to  ten  5'ears,  and  20  per  cent,  in  individuals  over  this 
age.  In  this  type  of  the  disease  complete  recovery  without  residual  paraly- 
sis may  occur  in  from  10  to  16  per  cent.  Death  occurs  most  frequently 
during  the  first  week,  and  commonly  results  from  paralysis  of  respiration. 
In  the  sporadic  form  death  is  very  rare,  and  complete  recovery  without 
sequelae  is  very  uncommon.  Within  a  few  hours  such  destruction  may  be 
wrought  among  the  anterior  horn  cells  that  the  patient  is  more  or  less 
crippled  for  life.  There  is,  however,  no  way  of  making  an  accurate  prog- 
nosis from  the  early  symptoms  as  to  the  amount  of  residual  paralysis.  The 
physician  is  therefore  justified  in  being  very  guarded  in  his  early  prog- 
nosis. He  may  comfort  the  family  by  telling  them  that  the  intellectual 
development  of  the  child  will  in  no  way  be  affected,  but  in  predicting  the 
amount  of  residual  paralysis  he  should  remember  that  there  is  a  possibil- 
ity that  the  child  may  almost,  if  not  completely,  recover.  After  a  month 
or  six  weeks  the  extent  of  the  residual  paralysis  may  be  approximately 
estimated  by  the  electrical  reactions  of  the  paralyzed  muscles;  those  that 
fail  to  respond  to  any  form  of  electrical  stimulation  will  probably  remain 
paralyzed. 


ACUTE    ANTEEIOR    POLIOMYELITIS  651 

The  prognosis,  so  far  as  improving  the  function  of  the  paralyzed  part, 
is  not  altogether  hopeless,  even  after  the  fourth  month.  Up  to  this  time 
the  improvement  is  progressive  and  spontaneous,  but  thereafter  improve- 
ment depends  upon  securing  the  greatest  possible  functional  development 
of  those  fibers  in  the  paralyzed  muscles  which  have  not  been  hopelessly 
damaged,  and  on  the  education  of  adjacent  muscles  to  the  partial  perform- 
ance of  the  functions  of  the  paralyzed  muscles. 

Prophylaxis.— These  patients  should  be  isolated  and  rigidly  quaran- 
tined, and  other  members  of  the  family  should  not  be  permitted  to  go  to 
school,  or  to  public  gatherings.  All  members  of  the  household,  especially 
those  who  must  necessarily  come  in  contact  with  the  patient,  should  use 
two  or  three  times  a  day  a  nasal  douche  or  spray  of  a  1  per  cent,  solution 
of  peroxid  of  hydrogen,  and  they  should  be  given  urotropin  in  from  2- 
to  6-grain  doses,  according  to  their  age,  three  times  a  day.  The  discharges 
from  the  throat,  nose,  kidneys  and  gastrointestinal  canal  of  the  patient 
should  be  disposed  of  in  such  a  manner  that  his  surroundings  may  not  be 
infected,  and  that  the  common  housefly  or  other  insects  may  not  carry  con- 
tagion to  other  parts  of  the  house.  A  rigid  quarantine  should  be  continued 
for  three  weeks,  and  house  disinfection  should  then  be  resorted  to,  as  de- 
tailed in  the  chapter  on  Scarlet  Fever.  Sprinkling  of  streets  and  lawns 
is  also  regarded  as  a  wise  prophylactic  measure. 

Treatment. — General  Treatment. — With  the  onset  of  acute  symp- 
toms, cold  applications  to  the  spine  are  indicated,  but  in  most  cases  the 
diagnosis  is  not  made  early  enough  to  give  the  patient  the  benefit  of  this 
treatment.  Absolute  quiet  and  rest  in  bed  should  be  insisted  upon.  Calo- 
mel in  small  doses  followed  by  Eochelle  salts  or  castor  oil  should  be  given 
to  move  the  bowels  and  control  intestinal  fermentation,  and  should  be 
followed  by  liquid  and  easily  digested  food.  Sedative  medication  to  re- 
lieve nervous  irritability  and  sleeplessness  may  be  indicated;  bromid  of 
soda  or  phenacetin  may  be  used  for  this  purpose.  Rarely  an  opiate  is 
necessary  to  allay  pain.  In  severe  cases  associated  with  meningeal  symp- 
toms, lumbar  puncture  may  relieve  the  pressure  and  slightly  modify  the 
symptoms.  In  these  cases  hypodermoclysis  with  normal  salt  solution  may 
be  a  life-saving  measure.  Strychnin  and  eaffein-sodium-benzoate  given 
hypodermically  may  be  of  value.  Whiskey  given  by  the  mouth  or  by  the 
rectum  is  valuable  in  all  cases  when,  for  any  reason,  sufficient  food  cannot 
be  taken. 

There  is  no  specific  medical  treatment  for  this  disease,  but  animal 
experimentation  indicates  that  hexamethylenamin  (urotropin)  should 
have  some  therapeutic  value,  not  only  as  a  prophylactic,  but  also  as  a  cura- 
tive, remedy.  My  experience  with  this  drug  in  the  epidemic  of  this  dis- 
ease which  prevailed  in  Cincinnati  in  1911  has  led  me  to  believe  that  it  has 
some  curative  value  if  given  early  and  in  large  doses.  From  the  onset  of  the 
acute  symptoms  it  should  be  given  in  from  3-  to  10-grain  doses,  according 
to  the  age  of  the  child,  every  four  hours,  and  this  dosage  should  be  con- 
tinued only  until  the  acute  symptoms  commence  to  abate.    In  one  appar- 


653  DISEASES    OF   THE    SPINAL   CORD 

ently  desperate  case  in  which  the  gastrointestinal  symptoms  were  so  vio- 
lent as  to  preclude  all  medication  by  mouth  or  rectum  for  a  period  of 
four  days,  the  child's  life  was  saved  by  hypodermoclyses  of  physiological 
salt  solution,  to  each  of  which  was  added  10  grains  of  urotropin. 

Treatment  of  the  Paralysis. — When  the  acute  symptoms  have  sub- 
sided and  the  child's  life  is  no  longer  in  danger,  attention  should  at  once 
be  directed  to  the  prevention  of  contractures  and  deformities  in  the  par- 
alyzed parts.  To  accomplish  this  the  paralyzed  portion  of  the  body  should 
be  maintained  in  as  nearly  a  normal  position  as  'possible  by  the  use  of  pil- 
lows, long  bags  of  sawdust,  or  by  light  braces,  or,  if  necessary,  strapping 
with  adhesive  plaster.  It  is  most  important  that  during  this  early  acute 
stage  the  paralyzed  muscles  and  their  tendons  and  the  ligaments  of  the 
joints  should  not  be  stretched  by  allowing  the  paralyzed  part  to  assume  an 
unnatural  position.  Apart  from  this  there  is  little  to  be  done  except  to 
feed  the  patient  carefully,  give  him  plenty  of  fresh  air,  and  shield  him 
in  every  possible  way  from  influences  that  might  produce  nervous  irrita- 
tion. Above  all  it  must  be  firmly  impressed  upon  the  parents  and  attend- 
ants that  for  at  least  two  weeks,  and  possibly  three,  following  the  disap- 
pearance of  acute  symptoms,  the  paralyzed  part  is  not  to  be  exercised  by 
massage,  electricity,  or  in  any  other  way.  Then  follows  a  long  period 
during  which  electricity,  massage,  and  active  and  passive  exercise  of  the 
paralyzed  part  will  be  of  great  advantage.  Electricity  promotes  the  nutri- 
tion and  keeps  up  the  function  of  those  muscles  and  muscle  fibers  which 
have  not  been  wholly  cut  off  from  their  communications  with  the  cord. 
The  faradic  current  may  be  used  for  those  muscles  which  respond  to  its 
use ;  other  muscles  more  seriously  affected  may  require  the  galvanic  current 
to  produce  a  contraction.  The  home  application  of  the  galvanic  current, 
however,  cannot,  as  a  rule,  be  easily  brought  about,  so  that,  in  the  great 
majority  of  instances,  the  faradic  current  alone  is  used,  and  this  is  sup- 
plemented by  systematic  massage.  Massage,  when  administered  by  a  skill- 
ful operator,  exercises  the  wasted  muscle,  increases  its  circulation  and 
promotes  its  nutrition,  and  is  perhaps  more  generally  applicable  in  pro- 
ducing these  results  than  is  electricity;  it  should  be  remembered,  however, 
that  in  beginning  this  treatment  the  weak  and  wasted  muscles  require  very 
gentle  massage;  strong  massage  may  further  weaken  and  injure  them.  As 
the  child  is  brought  gradually  under  treatment  the  most  satisfactory  re- 
sults are  obtained  by  the  daily  use  of  mild  systematic  massage  combined 
with  the  daily  use  of  the  faradic  current,  the  one  being  given  in  the  morn- 
ing and  the  other  in  the  afternoon.  This  routine  treatment  may  be  con- 
tinued daily  for  three  or  four  weeks,  and  then  for  a  long  period  the  mas- 
sage and  electricity  may  be  given  on  alternate  days.  As  soon  as  the  child 
has  recovered  sufficiently  to  use  the  paralyzed  part  great  good  may  result 
from  mechanical  appliances  properly  adjusted  by  an  orthopedic  surgeon; 
great  harm,  however,  may  follow  the  unskillful  use  of  heavy  braces;  the 
proper  use  of  these  appliances  should  assist  the  child  in  the  voluntary  use 
of  weak  muscles  without  aggravating  the  deformity,  which  has  probably 


MYELITIS  653 

already  resulted  from  the  unbalanced  contraction  of  muscles.  In  the  late 
treatment  of  these  cases  certain  operative  measures  are  of  value  in  reliev- 
ing deformities  and  improving  muscular  action.  By  lengthening,  shorten- 
ing, anastomosing,  or  transplanting  tendons,  muscular  action  may  be  util- 
ized which  was  previously  wasted,  and  loose  joints  may  be  made  much  more 
serviceable  by  fixing  them  by  ankylosis.  Muscle  training  is  a  very  im- 
portant part  of  the  treatment;  it  should  accompany  the  massage  after 
the  third  or  fourth  week  of  the  child's  illness,  and  should  follow  the  opera- 
tive measures  above  referred  to  in  the  subacute  and  chronic  cases.  The 
patient,  stripped  and  lying  on  a  table,  should  be  taught  to  make  move- 
ments which  will  exercise  and  thereby  develop  partially  wasted  muscles; 
in  the  beginning  it  may  be  necessary  for  the  instructor  to  assist  the  child 
in  making  these  movements.  Exercises  of  this  character  may  be  given  for 
half  an  hour  every  day  or  every  second  day  until  the  child  is  able  to  give 
up  his  braces. 

MYELITIS 

Myelitis  is  an  inflammation  of  the  spinal  cord  resulting  in  more  or 
less  disintegration  of  its  tissues.  The  white  matter  may  be  indistin- 
guishable from  the  gray,  and  both  may  present  the  appearance  of  red 
softening.  Capillary  hemorrhages  occur  and  the  anterior  horn  cells  of 
the  affected  areas  are  degenerated.  If  the  destructive  lesion  be  localized 
to  a  section  of  the  cord,  producing  a  more  or  less  complete  transverse 
myelitis,  the  sensory  fibers  of  the  posterior  and  cerebellar  columns  degen- 
erate upward  and  the  motor  fibers  of  the  pyramidal  tracts  degenerate  down- 
ward. The  transverse  forms  of  myelitis  most  frequently  occur  in  the  up- 
per half  of  the  cord;  the  dorsal  and  cervical  regions  are  favorite  sites.  In 
disseminated  myelitis,  resulting  from  syphilis  and  other  causes,  small  areas 
of  degeneration  may  be  scattered  throughout  the  cord. 

Etiology.- — ^lyelitis  is  produced  by  bacterial  infection.  In  childhood  it 
occurs  most  commonly  as  a  manifestation  of  syphilis,  or  as  a  complication 
of  tuberculosis  of  the  spine  (Pott's  disease) ;  in  this  latter  condition  there 
is  a  preliminary  compression  followed  by  inflammation.  It  may  occur  as 
a  sequel  of  one  of  the  acute  infectious  diseases  or  as  one  of  the  manifesta- 
tions of  a  septic  process  located  anywhere  in  the  body.  "Cold"  and  rheu- 
matism are  classed  among  the  exciting  causes.  Myelitis  may  result  from 
the  extension  downward  and  inward  of  meningitis  (meningomyelitis), 
and  may  be  produced  by  injury  to  the  spine,  new  growths  pressing  on  the 
cord,  and  by  spinal  hemorrhage,  but  whatever  may  be  the  exciting  factor 
the  most  destructive  lesions  are  inflammatory  and  are  produced  by  micro- 
organisms, most  commonly  streptococci  and  staphylococci. 

Symptomatology. — Transverse  Form. — Fever  and  constitutional  symp- 
toms exist  in  all  forms  of  myelitis.  They  are  much  more  marked,  however, 
in  the  acute  varieties  due  to  infection.  In  these  cases  we  may  have  a  sud- 
den onset,  temperature  rising  to  103°  or  10-4°F.,  with  more  or  less  severe 


654  DISEASES   OF   THE   SPIXAL   CORD 

pain  and  tenderness  over  tlie  spine,  and  within  twenty-four  or  thirt3'-six 
hours  the  characteristic  paralysis  may  begin  to  develop.  These  cases  are 
in  marked  contrast  to  the  much  more  common  ones  produced  by  Pott's 
disease  and  syphilis,  in  both  of  which  the  onset  is  insidious  and  the  febrile 
reaction  slight. 

To  clearly  understand  the  symptom  group  presented  by  myelitis,  one 
should  remember  that  the  character  and  severity  of  the  paralysis  will  de- 
pend upon  the  location  and  the  severity  of  the  lesion  in  the  cord.  In  my- 
elitis one  finds,  as  a  rule,  two  distinct  kinds  of  paralysis.  In  one  part 
of  the  body  the  paralysis  will  be  flaccid,  having  all  the  characteristics  of 
this  type  as  described  under  Acute  Anterior  Poliomyelitis.  In  another 
and  lower  part  of  the  body  the  paralysis  will  be  spastic,  having  all  the 
characteristics  of  this  type  as  described  under  Cerebral  Palsies.  Where 
the  lesion  is  located  in  the  cervical  portion  of  the  cord,  the  muscles  of  the 
arm  which  are  directly  innervated  by  the  anterior  cornual  cells  of  this  part 
of  the  cord  will  be  in  a  state  of  flaccid  paralysis,  with  loss  of  reflexes  in 
the  part,  and  sooner  or  later  atrophy  and  the  reaction  of  degeneration 
will  be  marked  in  the  paralyzed  muscles.  All  that  part  of  the  body  below 
the  .lesion  in  the  cervical  cord  will  be  in  a  state  of  spastic  paralysis,  which 
can  be  most  easily  recognized  in  the  legs.  The  leg  muscles  may  even  be 
contractured,  the  reflexes  are  exaggerated,  but  there  is  no  atrophy  or 
reaction  of  degeneration  in  the  paralyzed  muscles.  The  spastic  paralysis 
is  due  in  these  cases  to  the  descending  degeneration  of  the  fibers  of  the 
pyramidal  tract,  which  begins  at  the  point  of  the  cord  lesion  and  extends 
downward.  If  the  lesion  be  in  the  dorsal  portion  of  the  cord,  as  it  com- 
monly is,  the  arms,  and  all  of  that  part  of  the  body  above  the  lesion,  will 
be  free  from  paralysis,  and  the  muscles  of  the  trunk  directly  supplied  by 
nerve  fibers  from  the  diseased  portion  of  the  cord  will  be  in  a  state  of 
flaccid  paralysis,  while  the  legs  will  be  in  a  state  of  spastic  paralysis.  If 
the  lumbar  segment  of  the  cord  be  involved  in  the  myelitis,  there  will  then 
be  a  flaccid  paralysis  of  the  lower  extremities,  with  loss  of  knee-jerk  and 
other  reflexes,  since  the  cells  in  the  lumbar  cord  are  in  direct  communica- 
tion with  the  muscles  of  the  legs.  In  transverse  myelitis  the  paralysis  is 
symmetrical,  bilateral,  motor  and  sensory.  The  upper  line  of  the  paralysis 
is  sharply  limited  by  the  lesion  in  the  cord  and  is  marked  by  a  small  zone 
of  hyperesthesia,  sometimes  associated  with  a  sensation  of  belt-like  con- 
striction around  the  body.  Immediately  below  this  zone  the  various  forms 
of  sensation  are  almost  or  totally  lost;  complete  anesthesia  may  exist. 

Vesical  and  rectal  disturbances  are  among  the  characteristic  symptoms 
of  myelitis;  the  urine  is  retained  and  dribbles  away  from  an  overfull  blad- 
der, and  there  is  involuntary  discharge  of  feces.  The  character,  how- 
ever, of  this  disturbance  of  bladder  and  rectum  differs  with  the  localiza- 
tion. 

Bedsores  very  commonly  develop,  due  to  trophic  disturbances  of  the 
skin,  which  make  it  possible  for  slight  pressure  and  irritating  discharges 
to  produce  extensive  sloughing.     It  is  a  matter  of  the  greatest  difficulty 


MYELITIS  656 

in  these  cases  to  so  care  for  the  patient  as  to  prevent  the  formation  of 
bedsores. 

The  above  clinical  picture  is  that  ordinarily  presented  by  acute  my- 
elitis of  the  transverse  variety,  but  it  should  be  remembered  that  it  may  be 
very  greatly  modified  in  individual  cases,  and  the  modification  of  the  symp- 
toms will  depend  upon  the  location,  character  and  extent  of  the  lesions 
in  the  cord. 

Disseminated  Forms. — Tuberculous  myelitis  due  to  caries  of  the  spine 
is  the  most  common  form  of  this  disease  in  childhood ;  in  the  beginning  it 
is  purely  a  compression  myelitis,  and  the  paralysis  develops  very  slowly. 
During  this  early  stage  the  sharp  lancinating  pains  radiating  from  the 
spine  are  due  to  compression  of  the  nerve  roots.  This  is  an  early  and  prom- 
inent symptom  and  is  associated  with  marked  tenderness  over  the  spinous 
processes.  The  early  paralysis  that  develops  in  these  cases  is  spastic,  un- 
associated  with  the  flaccid  variety ;  it  occurs  most  commonly  in  the  legs,  but 
may  occur  in  the  arms.  The  reflexes  are  exaggerated,  and  hyperesthesia 
rather  than  anesthesia  is  present.  As  the  inflammatory  process  invades 
the  cord  unilateral  symptoms  may  appear,  but  after  a  time  these  are  re- 
placed by  the  symptom  group  above  given  of  ordinary  transverse  myelitis. 

Syphilitic  myelitis  is  slow  and  irregular  in  its  onset;  the  paralysis  may 
not  be  S3'^mmetrical,  is  never  so  well  marked,  and  in  this  form  of  the 
disease  the  distribution  of  the  paralysis,  conforming  above  to  the  flaccid 
and  below  to  the  spastic  type,  is  not  seen.  The  morbid  process  is  distrib- 
uted over  a  great  portion  of  the  cord  and  is  not  so  intense  at  any  one  level, 
so  that  there  may  be  great  variations  in  the  symptom  group  produced. 
Sensory  paralysis  may  not  always  be  associated  with  motor,  and  apparent 
recovery  followed  by  relapses  may  occur.  The  irregularity  of  the  symptom 
group  in  this  form  of  the  disease  makes  it  necessary  for  one  to  depend 
largely  upon  other  evidences  of  specific  disease  in  making  the  diagnosis. 

Progniosis. — In  compression  myelitis  due  to  Pott's  disease  the  prog- 
nosis, so  far  as  recovery  from  the  paralysis  is  concerned,  is  rather  favor- 
able if  the  diagnosis  is  made  early  and  proper  treatment  is  instituted 
before  the  cord  has  become  infected ;  from  50  to  60  per  cent,  of  these  cases 
recover.  In  neglected  cases,  where  infection  of  the  cord  has  taken  place 
and  a  complete  transverse  myelitis  has  resulted,  the  prognosis  'is  bad.  In 
syphilitic  myelitis  the  prognosis  is  good  if  an  early  diagnosis  is  made  and 
proper  treatment  is  instituted.  The  symptoms,  as  a  rule,  yield  to  anti- 
syphilitic  treatment.  In  syphilitic  cases  of  long  standing,  however,  while 
some  improvement  may  follow  the  treatment,  the  prognosis,  so  far  as 
ultimate  recovery  is  concerned,  is  bad.  In  acute  infectious  myelitis  the  prog- 
nosis will  depend  upon  the  location  and  severity  of  the  lesion  in  the  cord. 
The  higher  the  lesion  the  greater  the  danger.  The  more  destructive  the 
lesion,  as  indicated  by  the  severity  of  the  symptoms,  the  more  serious  the 
prognosis.  While  on  the  whole  the  prognosis  in  severe  lesions  located 
high  in  the  cord  is  bad,  it  is  not  wise  to  make  an  early  unfavorable  prog- 
nosis, since  it  is  quite  impossible  for  the  physician  to  foretell  with  accuracy 
43 


656  DISEASES    OF   THE    SPINAL   COED 

tlie  course  that  the  disease  will  take  in  an  individual  case.  One  may  gen- 
eralize and  say,  after  ohserving  the  case  for  two  weeks,  that  this  being  a 
mild  case  it  will  probably  recover,  or  this  being  a  severe  one  it  will  prob- 
ably die;  yet  it  should  always  be  remembered  that  in  a  few  of  the  severe 
cases  complete  recovery  takes  place.  In  those  cases  in  which  the  paralysis 
persists  for  months  the  great  danger  lies  in  the  complications,  such  as  bed- 
sores, cystitis  and  sepsis.  These  are  important  factors  in  producing  a 
fatal  termination  in  a  large  percentage  of  the  subacute  and  chronic  cases. 

Treatment. — Eest  in  bed  under  the  most  careful  nursing,  directed  es- 
pecially toward  the  prevention  of  bedsores  and  cystitis,  is  a  most  impor- 
tant part  of  the  treatment.  The  mattress  upon  which  the  patient  rests 
should  be  most  carefully  selected  with  reference  to  conforming  to  the  sur- 
face of  his  body  without  producing  undue  pressure  at  any  point.  Air  and 
water  mattresses  are  well  adapted  to  this  purpose.  From  the  beginning 
the  nurse  should  be  carefully  instructed  to  shift  the  patient,  when  awake, 
every  hour  or  two,  so  as  to  avoid  long  pressure  upon  any  one  part  of  the 
skin.  The  skin  should  be  rubbed  with  alcohol,  and,  if  slight  redness  oc- 
curs, with  zinc  ointment,  and  at  the  first  indication  of  a  developing  bed- 
sore all  pressure  should  be  removed  from  the  part,  and  every  effort  made 
to  restore  the  skin  to  its  normal  condition.  The  retention  of  urine,  which 
occurs  in  this  disease,  necessitates  the  use  of  the  catheter,  so  that  it  is  most 
important  in  the  beginning  that  the  nurse  should  be  carefully  instructed 
to  always  use  sterile  catheters,  anointed  with  sterile  vaselin,  for  only  in 
this  way  may  cystitis  be  prevented.  This  complication  is  a  much  dreaded 
one,  and,  in  the  event  that  infection  of  the  bladder  occurs,  it  should  be 
carefully  washed  out  two  or  three  times  a  day  with  an  alkaline  antiseptic 
solution.  The  dribbling  of  urine,  which  occurs  in  this  disease,  is  a  source 
of  danger  and  irritation,  and  the  patient  should  be  protected  from  it,  if 
possible,  by  the  proper  use  "of  cotton.  The  nutrition  of  the  patient  must  be 
carefully  kept  up  throughout  the  whole  course  of  the  disease  by  a  carefully 
selected  diet,  and  attention  to  the  digestive  organs.  Medication  that  inter- 
feres with  the  appetite  or  digestion  will  do  more  harm  than  good. 

In  myelitis  dug  to  Pott's  disease  the  aim  of  the  physician  should  be  to 
remove  the  pressure  from  the  cord  and  cure  the  tuberculosis  of  the  spine. 
To  remove  the  pressure  the  patient  should  for  a  time  be  placed  in  bed 
and  kept  absolutely  at  rest.  This  is  to  be  followed  by  a  plaster-of-Paris 
jacket,  so  applied  as  to  relieve  the  pressure  on  the  cord  and  partially  sep- 
arate and  prevent  the  rubbing  -together  of  the  diseased  spinal  vertebrae. 
With  the  jacket  properly  applied  the  patient  can  move  and  be  moved 
without  injury  either  to  the  cord  or  the  spine.  As  the  patient  progresses 
the  plaster  jacket  may  be  replaced  by  a  less  cumbrous  appliance  in  the 
form  of  braces,  which  will  allow  more  freedom  of  motion  and  at  the  same 
time  will  protect  the  cord  and  firmly  hold  the  spinal  column  until  com- 
plete ankylosis  of  the  diseased  vertebrae  makes  support  no  longer  neces- 
sary. This  part  of  the  treatment  should,  if  possible,  be  directed  l)y  an 
orthopedist.     During  all  the  time  the  above  mechanical  treatment  is  being 


HEREDITARY    ATAXIA  657 

carried  out  the  patient  should  be  treated  constitutionally  as  directed  in 
the  chapter  on  Tuberculosis.  Without  good  food  and  fresh  air  a  cure 
cannot  be  effected  in  these  cases. 

Syphilitic  myelitis  is  to  be  treated  with  mercury  and  the  iodids  as 
directed  in  the  chapter  on  Syphilis. 

In  acute  infective  myelitis  the  patient  is  to  be  put  to  bed  as  above 
directed.  Ice  may  be  applied  intermittently  to  the  spine  during  the  first 
four  or  five  days  if  it  does  not  irritate  the  patient.  As  soon  as  the  diag- 
nosis is  made,  30  c.  c.  of  antistreptococcic  serum  should  be  administered, 
and  this  dose  is  to  be  repeated  every  six  to  twelve  hours  until  six  doses 
liave  been  given.  Inunctions  of  unguentum  Crede,  2  drachms  every 
twelve  hours,  should  also  be  used  over  the  same  period  of  time.  This 
treatment  may  be  of  service  in  modifying  the  inflammation  if  the  infection 
1)6  streptococcic;  in  every  instance  where  the  myelitis  follows  one  of  the 
acute  infections  or  appears  without  apparent  cause  it  should  be  used. 

Residual  paralysis  and  contractures  are  to  be  treated  as  recommended 
under  Cerebral  Palsies. 

In  those  cases  that  are  fortunate  enough  to  make  a  favorable  conval- 
escence great  care  should  be  exercised  in  guarding  them  against  the  too 
early  use  of  the  muscles  weakened  by  paralysis.  These  muscles  require  a 
long  period  of  time  to  recover  their  normal  strength  and  tone,  and  satisfac- 
tory convalescence  may  be  interfered  with  by  subjecting  them  to  fatigue 
during  this  period. 

HEREDITARY  ATAXIA 

{Friedreich's  Disease) 

Hereditary  ataxia  is  an  hereditary  disease  of  the  spinal  cord  charac- 
terized by  degeneration  and  sclerosis  of  the  long  posterior  tracts,  the  cells 
of  Clark  and  those  of  Gowers  and  their  axons,  and  the  spinocerebellar 
tracts.  This  is  associated  with  a  lack  of  development  of  other  portions  of 
the  cord  and  of  atrophy  of  its  posterior  roots.  In  addition  the  process  fre- 
quently involves  the  lateral  (pyramidal)  tracts. 

Etiology. — Heredity  is  the  most  important  etiological  factor.  It  oc- 
curs as  a  family  disease,  extending  through  a  number  of  generations.  It 
is  a  disease  of  childhood,  beginning,  as  a  rule,  before  the  tenth  year  of 
life.    It  may,  however,  occur  in  early  infancy  and  in  adult  life. 

Symptomatology. — Ataxia  is  its  characteristic  symptom,  and  in  many 
respects  the  symptoms  resemble  those  of  locomotor  ataxia  in  the  adult. 
In  the  beginning  the  child  walks  with  his  legs  apart  in  an  awkward,  un- 
steady manner.  The  leg  is  lifted  carefully  and  brought  down  suddenly 
as  in  locomotor  ataxia.  Romberg's  sign  is  often  present;  that  is  to  say, 
when  standing  still  with  the  feet  close  together  there  is  a  swaying,  un- 
certain movement  of  the  body,  and,  if  the  eyes  are  closed,  the  patient  falls 
to  the  floor.  There  may  also  be  vibratory  movements  (choreiform)  of  the. 
head  and  eyes.     Later  the  ataxic  movements  become  well  marked  in  the 


658  DISEASES    OF   THE    SPINAL   CORD 

arms;  these  awkward,  jerky,  sudden  movements  of  the  arm  may  be  brought 
about  by  asking  the  patient  to  pick  up  some  object.  Later  on  there  is  more 
or  less  rigidity  of  the  muscles  of  the  arms  and  legs  which  greatly  interferes 
with  the  functions  of  these  parts.  Muscular  power  is  gradually  lost,  so 
that  late  in  the  disease  almost  complete  paralysis  may  result.  The  com- 
plete loss  of  the  knee-jerk  and  other  deep  reflexes  is  an  important  symptom. 
Speech  is  slow,  measured  and  diflEicult.  In  these  cases  the  instep  is  highly 
arched,  the  toes  hyperextended.  Late  in  the  disease  the  mind  of  the  patient 
may  be  dulled  and  his  expression  stupid,  though  often  the  mental  state 
remains  unimpaired. 

Eeflex  pupillary  rigidity  (Argyll-Eobertson  phenomenon)  and  ocular 
muscle  palsies  do  not  belong  to  the  picture  of  Friedreich's  disease  as  they 
do  to  tabes. 

Prognosis. — This  disease  is  invariably  progressive.  The  patient  in  a 
few  years  becomes  a  hopeless  cripple  and  perhaps  an  imbecile,  unable  to 
help  himself  in  any  way.  These  unfortunates  often  live  far  into  adult 
life. 

Treatment. — There  is  absolutely  no  treatment  that  favorably  influences 
the  course  of  this  disease.  It  becomes  the  duty,  however,  of  the  physician 
to  prolong  the  lives  and  minister  to  the  comfort  of  these  unfortunate  pa- 
tients. In  seeking  to  accomplish  these  ends  the  diet  may  be  carefully  su- 
pervised, that  it  may  serve  nutritional  purposes  and  come  within  the  range 
of  the  child's  digestive  capacity.  Outdoor  life,  wholesome,  hygienic  sur- 
roundings, and  careful  attention  to  the  gastrointestinal  canal  are  neces- 
sary. Orthopedic  apparatus  carefully  designed  to  support  weakened  joints 
and  prevent  contractures  may  add  to  the  comfort  of  the  patient. 

SPINA  BIFIDA 

This,  the  most  common  malformation  of  the  central  nervous  system 
in  infancy,  is  due  to  defective  development  of  the  vertebral  canal.  It 
usually  consists  in  an  absence  of  the  spinous  processes  of  one  or  more  ver- 
tebrae; the  lamina?  may  also  be  absent.  These  defects  open  up  the  spinal 
canal,  and.  through  this  opening  its  contents  protrude,  producing  hernia 
of  the  spinal  cord  or  its  membranes,  which  is  present  at  birth.  This  pro- 
trusion commonly  occurs  posteriorly  in  the  median  line  and  is  usually 
located  in  the  lumbar  or  sacral  regions.  In  rare  instances,  however,  the 
hernia  may  escape  through  a  defect  in  the  anterior  portion  of  the  spinal 
canal,  producing  a  tumor,  which  protrudes  into  the  lower  abdominal  or 
pelvic  cavities.  This  latter  condition  is  known  as  spina  bifida  anterior,  or 
occulta.  The  following  varieties  of  spina  bifida  are  recognized:  meningo- 
cele, meningomyelocele,  and  syringomyelocele.  They  are  commonly  asso- 
ciated with  other  congenital  deformities. 

Meningocele. — Meningocele  is  the  rarest  and  simplest  form  of  spina 
bifida.  It  is  a  simple  hernia  of  the  membranes  of  the  cord,  which  are 
pushed  through  the  opening  in  the  spinal  canal  by  the  fluid  in  the  arach- 


SPINA    BIFIDA 


659 


noid  cavity  or  subarachnoid  space.  The  spinal  marrow  remains  in  posi- 
tion and  the  hernial  tumor  consists  of  spinal  fluid,  held  by  the  globular 
dilatation  of  the  skin  and  arachnoid.  The  dura  mater  opens  posteriorly 
and  becomes  merged  in  the  walls  of  the  sac.  The  tumor  is  commonly  lo- 
cated in  the  lower  lumbar  or  sacral  region,  and  may  vary  in  diameter  from 
2  to  6  inches.  It  is  pedunculated,  translucent  and  not  associated  with 
paralysis  or  any  disturbance  of  the  functions  of  the  cord  or  nerves.  The 
spinal  defect  in  meningocele  is  commonly  smaller  than  in  the  more  serious 


Fig.  101.— Htdrencephalocelk  and  Spina  Bifida  in  an  Infant  One  Day  Old. 

forms  of  spina  bifida;  an  X-ray  picture,  therefore,  showing  but  a  slight 
opening  in  the  spinal  canal,  would  indicate,  in  connection  with  the  above 
symptom  group,  the  presence  of  this  form  of  spina  bifida. 

Meningomyelocele.— This  is  by  far  the  most  common  and  most  serious 
form  of  spina  bifida.  In  this  condition  the  accumulation  of  fluid  in  the 
anterior  subarachnoid  space  pushes  the  spinal  marrow  and  its  posterior 
membranes  backward  through  the  opening  in  the  spinal  canal,  producing 
a  true  hernia  of  the  cord  and  its  membranes.  A  cystic  tumor  is  thus 
formed  containing  the  disintegrated  and  attenuated  fibers  of  the  spinal 
cord    which  have  been  torn  by  the  pressure  of  the  fluid  which  carried  it 


660  DISEASES   OF   THE    SPINAL   COED 

into  the  sac.  Remnants  of  the  cord  are  blended  with  the  inner  layer  of 
the  sac,  and,  in  some  instances,  so  attached  to  its  central  wall  as  to  pro- 
duce a  restraining  band,  giving  the  tumor  a  slightly  grooved  or  indented 
appearance,  which  is  characteristic  of  this  form  of  spina  bifida.  The 
tumor  is  located  in  the  lower  lumbar  or  upper  sacral  regions;  it  may  vary 
from  1  to  4  inches  in  diameter ;  it  is  translucent,  but  not,  as  a  rule,  pedun- 
culated. The  most  characteristic  symptom  of  this  form,  however,  is  the 
paralysis,  spastic  or  flaccid,  of  the  lower  extremities  commonly  associated 
with  anesthesia  and  disturbances  of  the  functions  of  the  bladder  or  rectum. 
The  skin  covering  the  tumor  may  remain  normal,  but,  more  commonly, 
after  a  time,  it  becomes  dark-red  in  color.  In  some  instances  the  skin  cov- 
ering is  absent;  in  others  it  disappears  under  erosion  from  inflammatory 
processes;  in  these  cases  the  thin  wall  of  the  sac  may  rupture,  leading  to 
infection  of  the  cord  and  its  membranes,  which  soon  results  in  the  death  of 
the  patient. 

Syringomyelocele. — Syringomyelocele  is  a  rare  form  of  spinal  hernia 
produced  by  an  increased  pressure  of  fluid  in  the  central  canal  of  the  cord. 
This  pressure  results  in  pushing  the  posterior  half  of  the  cord  and  its 
covering  membranes  through  the  congenital  opening  in  the  spinal  canal, 
producing  a  tumor  so  resembling  meningomyelocele  that  it  cannot  with 
certainty  be  differentiated  from  it.  In  typical  cases,  however,  of  syringo- 
myelocele the  paralysis  of  the  lower  extremities  is  sensory,  the  motor  nerves 
not  being  markedly  involved.  It  is  commonly  associated  with  hydro- 
cephalus, the  dilated  ventricle  of  the  brain  being  in  direct  communication 
with  the  tumor  through  the  central  canal  of  the  cord. 

Diagnosis. — While  the  differential  diagnosis  of  meningomyelocele  and 
of  syringomyelocele  is  unimportant,  it  is  of  the  greatest  importance  tliat 
these  two  conditions  should  be  differentiated  from  the  mucli  rarer  form 
of  simple  meningocele.  The  absence  of  paralysis  and  of  other  symptoms 
pointing  to  disturbance  of  the  functions  of  the  cord,  with  an  X-ray  picture 
showing  but  a  small  defect  in  the  spinal  column,  would  justify  a  diagnosis 
of  meningocele  and  exclude  the  graver  forms  of  spina  bifida. 

Prog^iosis. — The  prognosis  in  simple  meningocele  is  favorable,  but  in 
the  other  forms  in  which  the  spinal  marrow  is  involved  the  prognosis  is 
very  unfavorable.  In  many  of  these  cases  the  sac  ruptures  during  labor, 
or  shortly  after  birth,  and  the  septic  infection  of  the  cord  and  its  mem- 
branes, which  quickly  supervenes,  produces  death. 

Treatment. — The  treatment  consists  in  protecting  the  tumor  from  fric- 
tion and  other  injury;  this  is  a  matter  of  no  little  difficulty.  Bandages, 
holding  soft  compresses  covering  the  tumor,  may  be  worn.  In  selected 
cases  the  most  satisfactory  treatment  is  the  removal  of  the  tumor  mass  by 
a  surgical  operation.  All  cases  of  simple  meningocele,  and  these  are  rare, 
should  be  referred  to  the  surgeon  for  operation.  All  cases  associated  with 
marked  paralysis  or  hydrocephalus  are  hopeless  and  cannot  be  benefited  by 
surgical  procedures.  Operation,  however,  is  to  be  recommended  in  all  in- 
fants suffering  from  spina  bifida  who  have  lived  to  be  6  or  7  months  of 


MULTIPLE    NEUKITIS  661 

age,  who  have  gained  in  nutrition,  and  who,  during  this  time,  have  shown 
satisfactory  evidence  of  increasing  mental  development  and  who  have  either 
no  paralysis  or  but  slight  paralysis  of  the  lower  extremities.  Under  no 
conditions  should  the  operation  for  spina  bifida  be  performed  until  the 
infant  has  shown  satisfactory  evidence  of  both  mental  and  physical  develop- 
ment, and  this  practically  precludes  operation  until  the  child  is  6  or  7 
months  old. 


CHAPTER   LXXXI 

DISEASES    OF    PERIPHERAL    NERVES 

MULTIPLE  NEURITIS 

Multiple  neuritis  is  an  inflammation  of  peripheral  nerves,  which  re- 
sults in  more  or  less  complete  loss  of  function  to  the  nerves  involved.  It  is 
usually  symmetrical  in  its  distribution. 

Etiology. — Diphtheria  toxins  are  the  most  common  cause  of  multiple 
neuritis  in  children.  In  the  report  of  the  collective  investigation  by  the 
American  Pediatric  Society,  paralysis  occurred  in  9.7  per  cent,  of  3,384 
cases  of  this  disease  which  had  been  treated  by  antitoxin.  It  appears, 
therefore,  that  the  antitoxin  treatment  of  diphtheria,  unless  administered 
early,  has  little  influence  in  preventing  the  subsequent  development  of 
neuritis.  Influenza  and  malaria  are  perhaps  the  next  most  common  causes 
of  this  disease  in  children,  and,  in  rare  instances,  it  may  follow  any  of 
the  acute  infections.  Alcohol  and  the  metallic  poisons,  such  as  arsenic, 
lead,  mercury  and  zinc,  which  so  frequently  produce  this  disease  in  the 
adult,  are  occasionally  found  as  exciting  factors  in  the  child.  Of  this 
group  of  poisons  Putnam  finds  that  arsenic  is  the  most  common  cause  of 
neuritis  in  children. 

Pathology. — Neuritis  may  be  either  parenchymatous  or  interstitial. 
The  parenchymatous  form,  which  occurs  in  diphtheria,  is  the  one  usually 
seen  in  children.  In  this  condition  the  evidences  of  the  acute  inflamma- 
tion of  the  nerve  are  absent,  and  in  its  stead  there  is  a  degenerative  process 
which  slowly  destroys  the  axis  cylinder  and  its  myelin  sheath;  the  neuri- 
lemma, or  the  sheath  of  Schwann,  however,  is  left  intact,  and  from  the  cells 
of  this  sheath  the  nerve  may  be  regenerated  and  its  function  restored.  In 
the  interstitial  form  of  this  disease,  which  may  be  caused  by  the  other 
acute  infections,  or  by  alcohol  and  the  metallic  poisons  (lead  excepted), 
there  is  also  a  degenerative  process  which  may  destroy  the  axis  cylinder 
and  the  myelin  sheath,  but  it  is  accompanied  by  an  acute  inflammation  of 
the  nerve,  causing  swelling,  redness,  tenderness,  acute  hyperemia,  inflltra- 
tion  with  round  or  oval  cells,  and  proliferation  of  connective  tissue.  The 
acute  inflammatory  process  in  the  nerve,  however,  subsides  early  and  the 
degenerative  process  proceeds  to  the  more  or  less  complete  destruction  of 
the  nerve.     In  this  form  of  neuritis  regeneration  and  restoration  of  func- 


663  DISEASES   OF   PP1R1PHP]RAL   NERVES 

tion  of  the  nerve  may  also  occur.     But  the  regenerative  process  is  slow, 
lasting  over  one  or  two  months. 

Symptomatology. — The  onset  may  be  marked  by  fever,  pain  and  gen- 
eral nervous  irritability,  but,  as  a  rule,  the  paralysis  develops  insidiously, 
unannounced  by  acute  symptoms. 

In  diphtheritic  neuritis  the  paralysis  nearly  always  begins  in  the  soft 
palate  and  pharynx.  Attention  is  called  to  this  fact  by  difficulty  in  swal- 
lowing, by  the  nasal  twang  of  the  voice  and  by  regurgitation  of  fluid  foods 
through  the  nose.  Examination  will  show  that  the  soft  palate  hangs  down 
and  does  not  rise  in  phonation.  Usually  there  are  anesthesia  of  the  mucous 
membrane  and  an  absence  of  the  palatal  reflex.  The  involvement,  generally 
bilateral,  is  occasionally  one-sided.  Frequently  there  is  involvement  of  the 
ocular  muscles  with  palsies,  and  especially  the  ciliary  muscle  with  loss  of 
accommodation.  Involvement  of  the  adducens  betrays  itself  by  squint 
and  the  inability  to  turn  the  eye  outward ;  occasionally  the  vocal  cords  are 
paralyzed,  resulting  in  hoarseness  and  aphonia.  When  these  symptoms 
occur  the  knee-jerk  should  be  carefully  examined,  as  a  diminution  in  this 
reflex  indicates  the  extension  of  the  paralysis  to  the  lower  extremities. 
The  subsequent  course  of  this  paralysis  is  similar  to  that  of  multiple  neu- 
ritis produced  by  other  causes. 

The  other  forms  commonly  develop  following  one  of  the  other  acute 
infections,  or  perhaps  without  apparent  cause.  In  these  cases,  without 
preliminary  throat  paralysis,  the  child  commences  to  have  an  unsteady  or 
ataxic  gait,  and  fails  to  use  its  feet  and  hands  in  a  proper  manner;  dur- 
ing this  stage  there  may  be  muscular  tremor  and  incoordination.  The 
paralysis  first  becomes  noticeable  in  the  parts  of  the  body  most  remote 
from  the  central  nervous  system;  "wrist-drop"  and  "foot-drop"  caused 
by  paralysis  of  the  extensors  of  the  wrist  and  foot  are  early  and  character- 
istic symptoms.  The  paralysis  may  then  gradually  extend  up  the  arms  and 
legs;  in  severe  cases  it  involves  the  muscles  of  the  trunk  and  neck  and 
produces  complete  general  paralysis,  the  patient  being  unable  to  make  a 
voluntary  movement.  He  lies  limp  and  helpless,  and  when  the  body  is 
lifted  the  head  falls  about  from  lack  of  muscular  support.  Such  wide- 
spread paralysis  should  always  suggest  multiple  neuritis.  The  paralysis, 
however,  is  not,  as  a  rule,  so  widely  distributed,  but,  whatever  may  be  the 
extent,  it  is  symmetrical,  and  is  associated  with  more  or  less  sensory  par- 
alysis. The  sensory  paralysis,  however,  is  not,  as  a  rule,  complete,  but 
partial  anesthesia  is  common,  especially  during  the  early  stages  of  the  dis- 
ease. This  complete,  symmetrical  motor  paralysis,  associated  with  disturb- 
ances of  sensation,  is  the  characteristic  paralysis  of  this  disease.  In  some 
cases,  however,  the  sensory  disturbances  are  not  well  marked,  and,  as  a  rule, 
they  disappear  long  before  the  motor  paralysis.  Pain  and  tenderness  along 
the  course  of  the  affected  nerves  are  characteristic  symptoms  in  nearly  all 
forms  of  neuritis,  except  that  produced  by  diphtheria;  in  this  form  they 
are  absent. 

The  nutritive  function  of  the  paralyzed  nerve  is  also  interfered  with; 


MULTIPLE    NEURITIS  663 

this  results  in  a  mild  form  of  muscular  atrophy,  nothing  like  so  marked 
as  that  which  occurs  in  anterior  poliomyelitis.  The  reaction  of  degenera- 
tion is  present  in  the  atrophied  muscles.  The  reaction  to  the  galvanic  cur- 
rent is  slow  and  feeble,  and  the  anodal  closure  contraction  is  greater  than 
the  cathodal  closure  contraction.  In  severe  cases  the  muscle  fails  to  re- 
spond to  any  form  of  electrical  stimulation;  in  these  cases  the  atrophy  is 
more  marked.  The  knee-jerk  is  commonly  absent,  and  other  reflexes  of 
the  paralyzed  part  are  diminished  or  lost. 

Cardiac  paralysis  from  involvement  of  the  vagus  and  respiratory  par- 
alysis from  involvement  of  the  phrenic  and  intercostal  nerves  may  occur, 
but  they  are  rarely  seen  except  in  the  diphtheritic  form  of  this  disease. 
In  cardiac  paralysis  there  may  be  few  or  no  warning  symptoms  and  death 
may  occur  quite  unexpectedly.  In  other  cases  the  condition  of  the  heart  is 
made  evident  by  an  irregular,  intermittent,  weak  pulse,  and  this  may  be 
associated  with  coldness  of  the  extremities  and  precordial  distress.  In 
respiratory  paralysis  there  is  more  or  less  disturbance  of  the  respiratory 
rhythm  with  cyanosis  and  dyspnea,  and  as  the  diaphragm  is  commonly 
paralyzed,  abdominal  respiratory  movements  are  absent;  these  symptoms 
are  associated  with  great  anxiety  on  the  part  of  the  patient. 

Diagnosis.— The  differential  diagnosis  of  multiple  neuritis  from  other 
forms  of  paralysis  in  childhood  is  outlined  under  Anterior  Poliomyelitis. 

Course. — The  paralysis  usually  increases  in  severity  or  remains  station- 
ary for  four  or  five  weeks.  Improvement  then  gradually  sets  in,  from  two 
to  four  months  being  required  for  the  complete  restoration  of  function. 
The  great  majority  of  these  cases  end  in  complete  recovery;  in  some  in- 
stances, however,  a  residual  paralysis  due  to  destruction  of  nerves  and 
atrophy  of  muscles  may  occur.  A  fatal  termination  from  cardiac  and 
respiratory  paralysis  is  rare,  gxcept  in  the  diphtheritic  form  of  this  disease. 

Treatment.— Absolute  rest  in  bed  and  freedom  from  conditions  that 
produce  nervous  irritation  should  be  insisted  upon.  Calomel  followed  by 
Eochelle  salts  or  castor  oil  should  begin  the  treatment.  The  dietetic  treat- 
ment of  these  eases  is  important,  since  a  disturbed  gastrointestinal  canal 
may  greatly  interfere  with  nutrition  and  unfavorably  influence  the  prog- 
ress of  the  disease.  A  careful  search  in  every  case  should  be  made  for  the 
cause  of  the  disease.  If  metallic  poisoning  should  be  found,  its  source 
should  be  removed  and  eliminative  treatment  instituted.  If  malaria  or 
syphilis  be  suspected,  the  specific  treatment  for  these  diseases  should  be 
given.  In  the  great  majority  of  cases  the  treatment  should  be  mildly 
eliminative  and  otherwise  symptomatic.  The  eliminative  treatment  con- 
sists in  mild,  warm  alkaline  baths,  in  the  free  use  of  water,  and  in  keeping 
the  excretory  organs  in  good  condition.  One  or  two  warm  baths  each  day 
will  not  only  promote  elimination  through  the  skin,  but  will  greatly  mod- 
ify the  pain  and  discomfort  from  which  these  patients  suffer.  Drinking 
large  quantities  of  water  should  also  be  insisted  upon,  as  this  is  one  of  the 
most  important  therapeutic  mea^ires.  Warm  applications  made  with  flan- 
nels or  hop  bags  may  modify  the  pain  and  tenderness  along  the  nerves. 


664  DISEASES   OF   PEKIPHEKAL   NEKVES 

Phenacetin  may  be  used  to  relieve  ])ain,  the  bromids  to  overcome  the  gen- 
eral nervous  irritability,  and  veronal  to  produce  sleep.  Opium  is  rarely,  if 
ever,  necessary,  and  should  be  avoided  except  in  those  cases  where  the  pain 
is  great  and  does  not  yield  to  simpler  measures.  The  objection  to  opium 
is  that  it  constipates  and  interferes  with  elimination  and  nutrition.  Elec- 
tricity and  general  massage  are  of  value  late  in  the  disease  in  keeping  up 
the  tone  and  nutrition  of  muscles  and  in  bringing  about  an  earlier  restora- 
tion of  function  in  the  paralyzed  parts.  They  are  to  be  used  as  directed 
under  Anterior  Poliomyelitis.  Strychnin,  iron,  cod-liver  oil  and  other 
tonic  treatment  may  be  employed  during  the  long  period  in  which  the 
restoration  of  function  to  the  paralyzed  muscle  is  being  brought  about. 
If  cardiac  and  respiratory  paralysis  threaten,  the  patient  should  be  kept 
absolutely  quiet  and  not  allowed  to  do  for  himself  anything  that  can  be 
done  by  others,  and  in  the  event  that  these  dangerous  symptoms  commence 
to  subside,  the  same  absolute  quiet  should  be  insisted  upon  for  a  week  or 
more  after  all  symptoms  of  this  character  have  disappeared.  In  such  cases 
a  fatal  termination  may  sometimes  be  precipitated  by  rising  up  in  bed. 
In  cardiac  failure  strychnin  and  strophanthus  are  indicated;  in  respira- 
tory failure  strychnin  is  perhaps  the  best  remedy;  these  drugs  should  be 
given  hypodermically. 

FACIAL  PARALYSIS 

(Bell's  Palsy) 

Etiology. — Facial  paralysis  is  due  to  a  paralysis  of  the  seventh  nerve. 
It  may  occur  in  the  new-born  from  injury  to  this  nerve  by  obstetrical  for- 
ceps or  from  pressure  of  the  face  against  the  pelvic  bones  during  protracted 
labor. 

In  older  children  facial  paralysis  may  be  due  to  a  peripheral  neuritis 
of  this  nerve  resulting  from  "cold."  These  cases  are  not  fully  under- 
stood and  are  usually  spoken  of  as  rheumatic,  although  there  may  be  no 
other  rheumatic  symptoms  present.  This  group  includes  all  the  idiopathic 
cases  for  which  a  definite  exciting  factor  cannot  be  found;  many  of  them 
are  perhaps  toxic  in  origin.  Another  group  of  cases  are  due  to  injury  of 
the  nerve  from  disease  of  the  petrous  portion  of  the  temporal  bone  pro- 
duced by  chronic  otitis  media  or  to  injury  from  mastoid  and  other  ear  and 
face  operations,  or  to  parotitis  and  other  inflammatory  and  traumatic  con- 
ditions involving  the  tissues  about  the  lobe  of  the  ear. 

Intracranial  lesions,  such  as  tumors  of  the  brain,  basilar  meningitis 
and  fracture  of  the  skull,  may  produce  this  same  form  of  palsy  without 
involving  other  nerves. 

Excluding  the  birth  palsies  the  disease  is  very  rare  during  infancy. 
In  early  childhood  the  ear  cases  are  most  commonly  seen,  and  after  the 
seventh  year  the  idiopathic  cases  are  most  frequent. 

Symptomatology. — The  palsy  is  purely  a  motor  one;  the  sensory  nerves 
are  not  involved;  there  are  no  pain  or  constitutional  symptoms.    The  par- 


FACIAL    PARALYSIS  665 

alysis  of  the  face  is  the  only  symptom,  except  in  those  cases  that  are  due  to 
internal  ear  or  intracranial  disease.  In  these  cases  the  symptoms  of  the 
causative  condition  were  present  before  the  paralysis  and  continue  after 
its  development.  There  is  a  complete  motor  paralysis  of  the  muscles  of 
one  side  of  the  face,  which  produces  a  characteristic  symptom  group;  the 
eye,  as  Bell  noted,  cannot  be  closed,  efforts  to  accomplish  this  being  asso- 
ciated with  an  upward  movement  of  the  eyeball;  the  face  on  the  affected 
side  is  expressionless  and  attempts  to  move  it  produce  grotesque  expres- 
sions. There  may  be  difficulty  in  talking,  the  child  mouthing  its  words. 
Whistling,  blowing,  laughing,  or  opening  the  mouth  develops  a  marked 
asymmetry  in  the  two  sides  of  the  face;  on  the  healthy  side  the  angle  of 
the  mouth  is  drawn  upward  and  the  deep  nasolabial  fold  is  in  contrast  to 
the  smooth  face  on  the  opposite  side.  In  lifting  the  eyebrows,  the  forehead 
on  the  paralyzed  side  remains  smooth  in  contrast  with  the  wrinkling  on 
the  opposite  side,  and  in  attempts  at  showing  the  teeth  the  mouth  assumes 
an  irregular  shape,  the  line  between  the  upper  and  lower  incisors,  instead 
of  being  continuous,  shows  deviation. 

In  those  cases  where  the  nerve  is  permanently  injured  atrophy  of  the 
muscles  occurs.  This  leads  to  a  wasting  of  one  side  of  the  face  and  to 
the  development  of  the  reaction  of  degeneration  in  the  paralyzed  muscles. 

Diagnosis. — From  other  forms  of  paralysis  facial  palsy  can  easily  be  dif- 
ferentiated by  remembering  that  it  is  a  motor  nerve  paralysis  confined  to 
the  muscles  of  the  face.  There  should  be  little  difficulty  in  determining 
the  cause  of  the  facial  palsy.  Intracranial  lesions,  such  as  meningitis  and 
brain  tumors,  announce  their  existence  by  characteristic  symptoms.  If 
facial  paralysis  be  associated  with  deafness  without  apparent  disease  of 
the  ear  and  weakness  of  the  outward  rotator  of  the  eye,  other  symptoms 
of  cerebellar  tumor  should  be  sought  for.  If  a  chronic  otitis  media  exists 
it  is  probably  the  cause  of  the  disease.  In  the  absence  of  other  causative 
factors  it  is  assumed  that  the  condition  is  due  to  cold  or  rheumatism  (idio- 
pathic). 

Progniosis. — The  prognosis  will  depend  largely  upon  the  causative  con- 
dition. In  birth  palsies  and  in  the  idiopathic  cases,  due  to  "cold,"  the 
prognosis  is  generally  good;  complete  recovery  occurs  in  from  one  to  six 
months.  The  electrical  reactions  in  these  cases  will  materially  assist  in 
determining  the  course  of  the  disease;  if  the  muscles  react  to  both  the 
faradic  and  galvanic  currents  in  a  normal  manner  at  the  end  of  the  first 
week,  recovery  will  be  rapid,  but  if  the  muscles  at  this  time  fail  to  respond 
to  the  faradic  current,  but  yet  respond  to  the  galvanic  current,  recovery 
may  not  be  expected  in  less  than  two  or  three  months.  In  the  more  se- 
vere cases,  where  the  muscle  not  only  fails  to  respond  to  the  faradic  cur- 
rent, but  shows  the  reaction  of  degeneration  to  galvanism,  and  contracts 
but  feebly  and  slowly  to  strong  currents,  the  paralysis  may  continue  for  a 
year,  and  in  some  cases  may  be  permanent.  The  prognosis  in  those  cases 
associated  with  disease  of  the  ear  will  depend  altogether  upon  the  charac- 
ter of  the  lesion.    If  the  nerve  be  cut  or  otherwise  destroyed,  the  paralysis 


666  DISEASES   OF   PERIPHERAL  NERVES 

may  be  permanent,  but,  in  the  majority  of  cases,  the  injury  to  the  nerve  is 
of  such  a  character  that  the  removal  of  the  exciting  cause  results  in  a  slow 
but  complete  recovery. 

Treatment. — Cases  due  to  disease  of  the  ear  or  temporal  bone  require 
proper  surgical  treatment.  Those  occurring  without  apparent  cause  may 
be  given  salicylate  of  soda,  as  recommended  in  the  chapter  on  Rheuma- 
tism; this  treatment  is  especially  indicated  if  the  facial  paralysis  is  asso- 
ciated with  sore  throat  or  pharyngitis.  The  salicylate  treatment,  however, 
should  not  be  continued  longer  than  three  or  four  days,  and  is  contrain- 
dicated  if  disease  of  the  ear  be  present.  Following  this  treatment  the  pa- 
tient's general  health  should  be  looked  after  by  proper  food,  outdoor  life 
and  tonics.  Iron,  cod-liver  oil  and  the  malt  preparations  may  be  indicated. 
The  most  important  part  of  the  treatment,  however,  consists  in  keeping  up 
the  nutrition  of  the  paralyzed  muscles,  and  this  should  be  done  by  massage 
and  electricity,  as  directed  under  Anterior  Poliomyelitis,  but  this  treatment 
should  not  be  begun  until  after  the  second  or  third  week.  In  the  use  of 
galvanism,  mild  currents  just  strong  enough  to  produce  muscular  contrac- 
tions should  be  used. 

Blisters  and  other  forms  of  counter-irritation  may  be  applied  beneath 
the  lobe  of  the  ear;  this  is  sometimes  of  value.  In  properly  selected  cases 
nerve  transplantation  may  be  of  benefit.  In  this  operation  the  facial 
nerve  is  cut  and  transplanted  in  the  sheath  of  the  hypoglossal  nerve.  Some 
good  results  have  been  reported  from  this  operation.  This  surgical  meas- 
ure is  indicated  only  in  those  cases  where  the  electrical  reactions  justify 
an  unfavorable  prognosis,  or  where  the  nerve  has  been  cut  in  surgical 
operations. 

PROGRESSIVE  MUSCULAR  DYSTROPHY 

This  term  is  used  to  embrace  a  group  of  syndromes  characterized  by 
more  or  less  widespread  atrophy  and  loss  of  function  of  the  voluntary 
muscles.  The  atrophy  is  associated  with  fatty  degeneration  of  muscle 
fibers  and  proliferation  of  connective  tissue.  In  the  pseudohypertrophic 
form  the  apparent  increase  in  size  of  certain  muscles  is  due  to  fatty  de- 
posits; a  true  hypertrophy,  however,  of  certain  muscle  fibers  also  occurs. 
In  the  peroneal  type  of  this  disease  (if  for  convenience  one  may  include  it 
under  this  heading)  the  peripheral  nerve  changes  discovered  by  Hoffman 
are  believed  to  be  the  cause  of  muscular  atrophy.  In  the  other  types  no 
changes  either  in  the  peripheral  or  central  nervous  system  have  been  found. 

Etiology. — The  causes  of  this  disease  are  unknown.  It  is  believed  to 
be  due  largely  to  hereditary  defects ;  at  any  rate  it  is  distinctly  hereditary, 
and,  although  boys  are  more  commonly  affected  than  girls,  tlio  hereditary 
transmission  occurs  almost  always  through  the  mother;  a  number  of  cases 
may  occur  in  the  same  family. 

Symptomatology. — Pseudohypertrophic  Form, — This  is  the  most 
common  of  the  clinical  types  of  this  affection.     It  develops,  as  do  all  the 


PROGRESSIVE  MUSCULAR  DYSTROPHY      667 

others,  slowly  and  insidiously,  unmarked  by  acute  constitutional  symptoms. 
It  begins,  as  a  rule,  between  the  second  and  seventh  years  of  life  is  char- 
acterized by  progressive  loss  of  strength  in  the  voluntary  muscles,  the  pa- 
tient becoming  more  and  more  helpless  until  he  is  hopelessly  bedridden. 
But  as  the  involuntary  muscles  are  not  involved  and  the  vital  organs  are 
not  affected,  the  patient  may  live  many  years,  to  die  from  some  inter- 
current disease. 

The  first  symptom  noticed  is  a  clumsiness  of  gait  associated  with  an 
increase  m  the  size  of  the  calf  of  the  leg.  There  is  a  notable  loss  of  power 
and  endurance  m  the  muscles  of  the  lower  extremities.  As  the  disease 
progresses  the  hypertrophy  of  the  calves  is  in  contrast  with  the  atrophy  of 
the  muscles  of  the  thigh,  back,  shoulder,  chest  and  upper  arm.  With  the 
increasing  atrophy  there  are  gradual  loss  of  power  and  final  loss  of  func- 


Fig.  102. — Progressive  Muscular  Dystrophy,  Pseudohypertrophic  Form. 

tion  on  the  part  of  the  muscles.  In  the  earlier  stages,  before  the  arm 
muscles  are  noticeably  involved,  the  patient  uses  his  hands  to  assist  in 
making  movements  that  are  ordinarily  accomplished  by  the  now  weakened 
muscles  of  the  leg  and  back,  and  in  doing  so  he  assumes  positions  which 
are  very  characteristic  of  this  disease.  Some  of  these  positions  are  illus- 
trated in  the  following  series  of  photographs  which  represent  different  posi- 
tions assumed  by  the  child  in  lifting  himself  from  the  floor.  If  placed 
on  his  back  the  patient  slowly  turns  on  his  face,  lifts  himself  upon  his 
arms,  and  then,  by  the  aid  of  his  hands,  "he  climbs  up  himself"  until  he 
finally  reaches  the  upright  position,  and  then,  with  legs  widely  separated, 
he  walks  with  a  clumsy  waddling  gait.  The  forward  curvature  of  the 
spine,  which  increases  with  the  wasting  of  the  deep  muscles  of  the  back, 
is  shown  in  the  accompanying  figures.  The  reflexes  are  diminished  in  the 
atrophied  parts  and  the  electrical  reactions  are  feeble.  As  the  disease 
progresses  the  patient  finally  becomes  a  helpless,  bedridden  invalid.    Nystag- 


668 


DISEASES   OF   PERIPHERAL   NERVES 


mus,  difficulty  in  speech,  and  lack  of  mental  development  may  be  present  in 
these  cases. 

Erb^s  Juvenile  Type. — This  form  usually  occurs  between  the  tenth 
and  sixteenth  year,  and  begins  in  the  muscles  surrounding  the  shoulder. 
They  gradually  lose  their  power,  and  may  be  wasted  or  hypertrophied. 
With  the  loss  of  function  in  these  muscles  the  patient  is  unable  to  lift  his 
arms,  the  atrophy  extends  to  other  muscles  of  the  upper  arm,  back,  thighs, 
and  legs.  With  the  atrophy  and  progressive  loss  of  function  of  these  muscles 
the  patient  gradually  loses  the  power  of  locomotion,  and  becomes  as  help- 
less as  in  the  pseudohypertrophic  type. 

Landouzy-Dejerine  Type. — This    type,  like    the    pseudohypertrophic 


Fig.  103.— Same  as  Fig.  102. 


type,  begins  in  early  life,  but  is  differentiated  from  the  others  by  the  fact 
that  the  muscular  atrophy  begins  in  the  face.  It  is  first  noticed  about  the 
mouth;  the  lips  are  thickened  and  everted,  the  mouth  is  slightly  open, 
the  patient  being  unable  to  close  it.  The  muscles  of  the  lower  part  of  the 
face,  neck  and  shoulder  girdle,  gradually  become  involved  with  a  progressive 
muscular  atrophy  and  loss  of  function.  The  subsequent  history  of  these 
cases  is  similar  to  those  of  the  Erb  type. 

Peroneal  Type. — This  type  of  muscular  atrophy  is  usually  classed  as 
a  separate  disease,  since  it  is  believed  to  be  due  to  degenerative  changes  in 
the  peripheral  nerves.  The  atrophy  begins  in  the  muscles  of  the  feet  and 
spreads  to  the  muscles  of  the  calf,  producing  a  general  atrophy,  and  in 
time,  complete  loss  of  power  of  the  muscles  below  the  knee;  the  disease. 


DISOEDERS    OF    SLEEP 


GG9 


as  a  rule,  is  confined  to  this  part  of  the  body,  but  it  may  spread  to  the 
thigh,  hand,  forearm  and  shoulder. 

Sensor}'  changes  in  the  atrophied  part  may  be  present,  but  total  loss  of 
sensation  is  uncommon.  The  reflexes  below  the  knee  and  in  other  atrophied 
portions  of  the  body  are  dimin- 
ished or  lost.  Although  these  pa- 
tients are  hopelessly  crippled, 
they  may  live  for  a  long  time. 
In  those  cases  where  the  disease 
is  limited  to  the  legs  below  the 
knees  the  prognosis,  so  far  as  life 
is  concerned,  is  especially  good; 
in  the  other  cases,  however,  where 
the  disease  extends  to  the  thighs, 
arms,  shoulders  and  other  volun- 
tar}'  muscles,  the  patients  become 
hopelessly  bedridden,  and  usually 
die  from  some  intercurrent  dis- 
ease. 

Treatment. — All  of  the  above- 
named  types  are  progressive  and 
run  their  course  uninfluenced  by 
any  kind  of  treatment.  All  the 
physician  can  do,  therefore,  is  to 
treat  them  symptomatically  and  look  to  their  general  health.  They  should 
be  carefully  fed,  live  an  outdoor  life,  and  be  placed  under  the  best  hygienic 
conditions.  As  long  as  they  are  able  to  use  their  muscles  they  should  be 
allowed  to  do  so.  In  accomplishing  this  end  orthopedic  appliances  to  over- 
come contractures  and  to  support  the  spine,  the  ankles,  and  the  knees  may 
be  of  great  service  in  keeping  the  patient  on  his  feet  for  a  longer  time  than 
would  otherwise  be  possible. 

Massage,  passive  movements  and  electricity  may  be  used  to  promote 
circulation  and  stimulate  the  nutrition  of  the  slowly  degenerating  muscles. 


FiQ.  104.— Same  as  Fig.  102. 


CHAPTER    LXXXII 

GENERAL  NERVOUS  DISEASES 

DISORDERS  OF  SLEEP 

Sleep  is  the  physiological  rest  which  the  tired  organism  demands  to 
repair  the  fatigue  changes  incident  to  the  physiological  activity  of  cells, 
especially  those  of  the  nervous  and  muscular  systems.  The  physiological 
activity  of  all  the  organs  of  the  body  alternates  with  periods  of  relative 
repose      This  repose  is  absolutely  necessary  to  the  vital  activity  of  cells. 


670  GENERAL  NERVOUS   DISEASES 

In  the  higher  animals  the  central  nervous  system  rests  at  least  once  in 
twenty-four  hours,  and  this  condition  of  rest  is  called  sleep.  Normal  sleep 
is  characterized  by  loss  of  consciousness,  loss  of  voluntary  inhibitory  con- 
trol of  motor  and  mental  acts,  and  more  or  less  complete  loss  of  all  the 
special  senses.  Sight  goes  first,  probably  taste  and  smell  next,  and  finally 
touch  and  hearing  disappear  as  sleep  becomes  profound.  During  sleep  all 
of  the  higher  functions  of  the  brain  are  held  more  or  less  in  abeyance, 
and  the  involuntary  inhibitory  control  of  motor  and  mental  acts  is  also 
partially  lost.  The  discharge  of  nervous  stimuli  to  all  the  organs  of  the 
body  is  greatly  diminished,  and,  as  a  result,  there  are  more  or  less  relaxation 
of  the  muscular  system  and  a  feebler  functional  activity  of  nearly  all  the 
important  glands. 

During  sleep,  however,  the  capacity  of  the  central  nervous  system  to 
react  to  peripheral  stimuli  is  not  altogether  lost.  But  the  more  profound 
the  sleep  the  stronger  must  the  peripheral  stimulation  be  to  make  any  im- 
pression upon  the  nerve  centers.  In  the  very  beginning  of  sleep  the  nerv- 
ous system  may  respond  very  actively  to  slight  external  stimuli,  producing 
muscular  twitchings  of  the  body,  which  may  be  severe  enough  to  arouse 
the  individual  with  the  knowledge  that  this  spasmodic  contraction  has  oc- 
curred. These  phenomena,  however,  are  more  likely  to  occur  in  highly 
nervous  individuals,  the  nervousness  being  produced  by  unusual  activity 
of  the  brain  before  going  to  bed,  or  by  an  excitable  condition  of  the  higher 
nerve  centers  produced  by  toxins.  While  this  condition  of  increased  reflex 
excitability  at  the  beginning  of  sleep  can  scarcely  be  said  to  be  physiologi- 
cal, yet  it  is  made  possible  by  the  fact  that  the  higher  nerve  centers,  which 
exercise  inhibitory  control  over  the  lower,  are  the  first  to  lose  their  func- 
tions under  the  influence  of  sleep;  and,  as  sleep  becomes  more  and  more 
profound,  the  entire  nervous  system  gradually  sinks  into  a  condition  of 
more  or  less  complete  repose,  the  motor  centers  at  the  base  of  the  brain, 
and  the  reflex  centers  of  the  cord  being  the  last  to  come  under  its  sedative 
influence.  When  the  entire  nervous  system  has  come  under  the  influence  of 
profound  sleep,  the  reflex  centers  of  the  brain  and  cord  are  not  so  readily 
excited  to  action  by  peripheral  stimuli  as  they  are  in  the  beginning  of  sleep, 
when  the  inhibitory  centers  are  in  repose,  and  the  motor  centers  have  not 
yet  lost  their  normal  excitability.  During  the  first  hour  sleep  becomes  more 
and  more  profound.  At  the  end  of  this  time  the  higher  nerve  centers  are 
very  profoundly  under  its  influence,  and  it  requires  comparatively  power- 
ful stimuli  to  bring  the  individual  back  to  consciousness.  During  the  sec- 
ond hour  sleep  becomes  gradually  less  profound,  and  from  this  time  on  a 
comparatively  slight  stimulus  is  sufficient  to  awaken  the  individual.  The 
profound  sleep  of  the  first  two  hours  has  been  likened  to  a  condition  of 
narcotism,  which  slowly  passes  off,  leaving  the  individual  still  unconscious, 
but  easily  aroused.  The  lower  motor  centers  of  the  brain  and  spinal  cord 
maintain  about  the  same  degree  of  irritability  from  the  beginning  to  the 
close  of  sleep.  They  are  apparently  not  influenced,  as  the  higher  centers 
are,  by  the  narcotism  of  the  first  and  second  hours  of  sleep. 


DISORDEES    OF    SLEEP  671 

The  healthy  newly  born  infant  sleeps  nearly  all  of  the  time,  at  least 
twenty  out,  of  the  twenty-four  hours.  During  the  first  month  the  normal 
infant  is  awake  about  four  hours  in  the  twenty-four.  From  this  time  on 
the  child  requires  slightly  less  sleep,  so  that  at  six  or  eight  months  he  is 
sleeping  sixteen  hours  in  the  twenty-four,  and  at  the  age  of  one  year  he 
sleeps  from  twelve  to  fourteen  hours.  During  the  first  few  days  of  life 
sleep  is  heavy,  owing  to  the  fact  that  the  organs  for  receiving  and  carrying 
peripheral  stimuli  to  the  central  nervous  system  are  not  yet  fully  developed. 
From  this  time  on  during  the  next  month  sleep  becomes  less  profound, 
and  from  the  end  of  the  third  month  to  the  end  of  the  second  year  sleep 
is  not  so  deep  as  it  is  after  the  third  or  fourth  year,  when  the  heavy  sleep 
of  childhood  is  seen.  It  is  at  this  time  in  the  life  of  the  individual  that 
the  profound  narcotism  of  the  early  hours  of  sleep  is  most  noticeable. 

The  most  common  disorders  of  sleep  are  night-terrors,  somnambulism, 
and  insomnia.  Of  these  the  most  important  is  night-terrors,  or  pavor  noc- 
turnus. 

PAVOR     NOCTURNUS 

Pavor  nocturnus  is  a  neurosis  dependent  upon  an  abnormally  irritabk 
nervous  system,  easily  excited  by  reflex  stimuli  having  their  origin  in 
distant  parts  of  the  body,  or  in  the  cortical  centers  themselves.  It  is  char- 
acterized by  a  night-terror  which  finds  expression  in  the  child's  screaming 
or  crying  out  in  a  panic  of  fright  during  sleep. 

Etiology. — Predisposing  Causes. — Heredity  is  a  very  potent  etiological 
factor.  In  the  most  severe  cases  there  is  commonly  a  well-marked  neurotic 
family  history,  and  such  neuroses  as  epilepsy,  hysteria,  chorea,  migraine  and 
neurasthenia  not  uncommonly  occur  in  the  family  histories.  This  strong 
hereditary  taint  predisposes  these  children  to  muscular  twitchings,  convul- 
sions and  reflex  neuroses  of  all  kinds.  The  particular  defect  of  the  nerv- 
ous system  which  is  inherited  is  a  feeble  inhibitory  control  of  mental 
processes  and  motor  acts.  This  may  explain  the  relationship  existing  be- 
tween epilepsy,  infantile  eclampsia,  and  night-terrors,  which  appear  to  be 
present  in  some  families.  Beyond  this  there  is  perhaps  no  direct  connec- 
tion between  these  neuroses.  While  a  neurotic  family  history,  resulting  in 
an  extremely  irritable  nervous  system  under  feeble  inhibitory  control,  is 
present  in  many  of  the  more  severe  cases  of  night-terrors,  this  factor  is  by 
no  means  so  well  marked  in  the  milder  types  of  this  disorder.  In  some 
instances  the  excitable  nervous  system  seems  to  be  wholly  dependent  upon 
other  factors  entirely  foreign  to  hereditary  influences. 

Malnutrition  is  an  important  factor  in  developing  irritability  of  the 
nervous  system  in  young  children,  and  the  common  causes  of  malnutrition, 
such  as  lymph-node  tuberculosis,  chronic  diseases  of  the  gastrointestinal 
tract,  chronic  malaria,  hereditary  syphilis,  and  rachitis,  with  improper  food, 
impure  air,  and  bad  hygiene,  may  therefore  be  important  predisposing  fac- 
tors of  night-terrors. 

Mental  overwork  and  excitement,  when  coupled  with  physical  in- 
44 


672  GENERAL  NERVOUS  DISEASES 

feriority,  are  most  potent  factors  in  producing  the  highly  irritable  state 
of  the  nervous  system  which  makes  possible  the  develo})ment  of  this  syn- 
drome. School  life;,  with  its  mental  grind,  persistent  excitation,  close  con- 
finement, and  eye-strain,  may  be  a  factor  in  the  development  of  night-ter- 
rors. 

Exciting  Causes. — The  normal  irritability  of  the  nervous  system  of 
the  child,  having  been  exaggerated  by  bad  heredity,  malnutrition,  mental 
overwork,  or  nervous  excitation,  makes  it  possible  for  certain  reflex  ex- 
citing causes  to  develop  an  attack  of  night-terrors.  The  intestinal  canal 
is  one  of  the  most  important  sources  of  this  reflex  irritation;  undigested 
food,  improper  food,  excess  of  food,  intestinal  worms,  and  intestinal  fer- 
mentations, with  the  intestinal  toxins  which  they  produce,  may  all  act 
either  directly  or  indirectly  as  exciting  factors.  Adenoids,  enlarged  ton- 
sils, and  nasal  obstructions  that  interfere  with  normal  breathing  during 
sleep,  may  either  act  as  reflex  factors  or  they  may  act  by  producing  a 
partial  asphyxia,  and  thus  excite  an  attack  of  night-terrors. 

In  many  cases,  however,  the  reflex  factors  are  absent,  or  perhaps  it 
might  be  better  to  say  are  so  slight  that  they  cannot  be  readily  discov- 
ered. In  these  cases  the  attack  is  apparently  excited  by  a  horrible  dream, 
which  has  its  origin  either  in  some  alarming  occurrence  of  the  previous 
day  or  in  the  overstimulation  of  the  emotional  centers  b)'  blood-curdling 
tales  or  exciting  fairy  stories.  The  nervous  systems  of  extremely  neurotic 
children  may  be  so  excited  by  punishment,  by  fits  of  anger,  and  by  fright 
that  they  fall  asleep  with  the  incidents  of  the  day  still  impressed  upon 
their  nervous  systems,  and,  as  a  result,  the  cortical  centers  do  not  come 
profoundly  under  the  reposeful  influences  of  sleep,  and  in  the  paroxysm 
of  night-terrors  which  supervenes,  the  horrible  vision  which  presents  itself 
to  the  child  in  his  night-terror  is  but  an  exaggerated  reflex  of  some  mental 
impression  which  he  received  during  the  day. 

Symptomatology. — Silbermann  divided  night-terrors  into  two  rather 
distinct  clinical  types,  which  for  the  most  part  have  been  recognized  by 
recent  writers.  One  of  these  he  called  Idiopathic  Xight-Terrors,  and  the 
other  Symptomatic  Night-Terrors.  The  idiopathic  type  is  of  central  or 
cortical  origin,  and  the  symptomatic  of  peripheral  origin.  In  the  de- 
scription which  follows,  these  two  types  will  be  recognized. 

NIGHT-TEREORS 

Central  or  idiopathic  night-terrors  has  for  its  most  important  etiologi- 
cal FACTOR  an  extremely  excitable  nervous  system  under  feeble  inhiljitory 
control,  which  has  been  inherited  from  neurotic  parents.  In  the  family 
history  of  these  cases,  hysteria,  neurasthenia,  and  the  convulsive  neuroses, 
all  of  which  are  largely  dependent  upon  feeble  inhibition,  are  common. 
The  inherited  neurotic  condition  may  also  be  aggravated  by  malnutrition 
and  improper  training.  There  can  be  little  doubt,  however,  that  even  in 
these  cases  peripheral  irritation  plays  a  part  in  touching  off  the  paroxysm ; 


DISOKDERS    OF    SLEEP  673 

but  the  central  nervous  system  is  in  such  a  state  of  excitability,  and  under 
such  feeble  inhibitory  control,  that  a  slight  peripheral  irritation  produces 
a  maximum  result,  and  for  these  reasons  it  is  commonly  disregarded  or 
overlooked.  Idiopathic  night-terrors  occur  in  the  great  majority  of  in- 
stances between  the  ages  of  two  and  eight  years.  This  is  the  period  of 
life  when  feeble  inhibitory  control  of  cortical  and  other  centers  is  respon- 
sible for  many  of  the  graver  nervous  diseases,  such  as  eclampsia,  epilepsy 
and  chorea. 

The  Paroxysm. — A  neurotic  child,  with  his  nervous  system  unusually 
excited  by  the  incidents  of  the  day,  falls  asleep,  and  after  an  hour  or  two 
suddenly  starts  in  his  sleep  with  a  cry  of  terror  that  alarms  the  household. 
A  moment  later  he  is  found  apparently  wide  awake,  sitting  up  in  bed,  or 
crouching  on  the  floor  in  a  state  of  wild  excitement,  staring  and  pointing 
at  some  horrible,  imaginary  object  wliich  he  seems  to  see  with  great  dis- 
tinctness. He  trembles  with  fear  and  gesticulates  wildly,  calling  for  as- 
sistance, but  when  spoken  to  fails  to  recognize  his  nurse,  who  is  vainly 
endeavoring  to  arouse  him  to  consciousness.  He  may  call  out  the  name  of 
some  man  or  animal  who  he  thinks  is  about  to  do  him  injury.  After  a  few 
minutes  of  this  agonizing  fear  the  attack  spends  its  force,  the  excitement 
gradually  passes  away,  and  the  little  patient  falls  back  upon  the  pillow 
and  becomes  quiet  in  sleep,  which  may  continue  without  further  disturb- 
ance until  morning.  In  many  instances  the  child  will  go  through  an  at- 
tack of  this  kind  without  recovering  consciousness;  in  other  words,  the 
whole  attack  occurs  during  sleep.  In  other  instances  the  strenuous  efforts 
of  the  attendants  may  arouse  the  child  to  a  vague  consciousness,  or, 
rather,  semiconsciousness,  during  which,  in  a  dazed  way,  he  recognizes 
his  surroundings,  and  then  quickly  drops  asleep,  and  the  next  morning  has 
little  or  no  recollection  of  what  has  occurred  during  the  night.  According 
to  Silbermann,  Coutts,  and  other  observers,  the  seeing  of  visions  is  the  most 
characteristic  feature  of  these  attacks  of  central  or  idiopathic  night-ter- 
rors. Similar  attacks  may  occur  for  a  number  of  nights  in  succession,  or 
there  may  be  an  interval  of  weeks  or  months  between  them,  but  they  al- 
ways present  very  much  the  same  clinical  picture,  although  they  vary  in 
intensity. 

Incontinence  of  urine  may  occur  or  the  child  may,  at  the  close  of  the 
attack,  make  known  his  wants,  and  after  seeking  the  commode  pass  urine 
or  have  a  movement  from  the  bowels,  as  though  he  were  entirely  conscious 
of  his  actions,  and  yet  give  no  other  evidence  of  being  conscious  of  his 
surroundings.  He  returns  to  bed,  continues  his  sleep,  and  the  next  morn- 
ing has  no  recollection  of  these  occurrences. 

The  central  type  of  night-terrors  is  believed  by  many  writers  to  be 
closely  related  to  "epilepsy,  and  quite  a  number  of  cases  of  epilepsy  have 
been  reported  in  which  night-terrors  occurred  as  a  part  of  their  early  his- 
tory. Concerning  this  relationship,  however,  I  am  quite  in  accord  with 
the  opinion  expressed  by  Charles  Putnam  in  his  excellent  paper  on  this 
subject  in  the  "Cyclopedia  of  the  Diseases  of  Children."    He  says:    "Al- 


674  GENERAL  NERVOUS  DISEASES 

together,  the  cormeetion  between  night-terrors  and  epilepsy,  in  so  far  as 
they  are  separate  diseases,  is  no  clearer  than  that  between  any  two  of  the 
neuroses,  and  yet,  inasmuch  as  attacks  closely  resembling  night-terrors  are 
occasionally  only  symptoms  of  epilepsy,  it  is  well  to  watch  carefully  for  a 
time  before  deciding  that  epilepsy  is  not  present." 

Symptomatic  night-terrors  are  more  common  in  childhood,  but  may  oc- 
cur at  any  age,  and  are  much  more  frequent  than  idiopathic  night-terrors. 
In  symptomatic  or  peripheral  night-terrors  the  essential  etiological  fac- 
tor is  outside  the  nervous  system  in  some  peripheral  excitation.  Children 
suffering  from  this  symptom-complex  have,  as  a  rule,  unstable  and  irri- 
table nervous  systems,  but  this  nervous  instability,  instead  of  being  heredi- 
tary, is  usually  acquired.  Chronic  malnutrition  and  other  factors  capable 
of  producing  an  unstable  nervous  system  in  an  otherwise  healthy  child 
may  commonly  be  observed.  The  reflex  factors  above  noted  as  having 
their  origin  in  the  intestinal  canal,  nose,  throat,  and  other  organs  are 
present,  and  can  usually  be  very  readily  discovered. 

The  Paroxysm. — The  child  falls  asleep  and  may  toss  restlessly  for  an 
hour  or  two  before  the  reflex  irritation  to  the  nervous  centers  culminates  in 
an  attack  of  night-terrors.  The  patient  screams  with  terror,  sits  up  in 
bed,  or  runs  about  the  room.  He  is  wildly  excited,  trembles  with  fear,  and 
exhibits  a  very  marked,  but,  as  a  rule,  undefined,  terror.  He  sees  no  visions 
and  hears  no  noises,  and  responds  to  the  efforts  of  his  attendants  to  arouse 
him.  He  recognizes  his  attendants  and  seeks  consolation  from  them.  His 
nervous  fears  are  soon  quieted,  and  he  falls  asleep,  to  awaken  the  next 
morning  with  perhaps  a  vague  recollection  of  the  occurrences  of  the  night. 

Clinical  Pictures. — Silbermann,  and  after  him  Coutts,  have  called  at- 
tention to  the  differences  in  the  clinical  pictures  portrayed  in  the  two  types 
of  night-terrors.  Coutts  uses  the  term  nightmare  to  describe  the  class  of 
cases  which  Silbermann  speaks  of  as  symptomatic  or  peripheral.  As 
Coutts  puts  it,  the  chief  distinction  between  these  two  symptom  groups  is 
that  the  one  suffering  from  idiopathic  night-terrors  "sees  visions,"  while 
the  one  suffering  from  symptomatic  night-terrors  merely  "dreams  dreams." 
Silbermann  expresses  the  same  idea  by  saying  that  the  former  is  charac- 
terized by  objective  terror  and  the  latter  by  subjective  terror.  It  may  be 
added  also  that  in  the  idiopathic  form  the  terror  is  more  real,  the  mental 
excitement  greater,  and  the  condition  of  unconsciousness  more  profound. 

Notwithstanding  the  differences  in  the  clinical  pictures  which  the  two 
types  of  night-terrors  present,  I  am  not  prepared  to  say  that  they  are  dis- 
tinct clinical  entities.  I  am  rather  inclined  to  believe  that  the  idiopathic 
type  of  this  disorder  presents  the  aggravated  clinical  picture  as  it  may 
occur  in  highly  neurotic  children,  whose  mental  and  motor  mechanisms  are 
under  feeble  inhibitory  control.  Between  this  extreme  type  and  the  milder 
attacks  of  symptomatic  night-terrors,  due  almost  wholly  to  strong  reflex 
excitation  of  an  almost  normal  nervous  system,  there  is  indeed  a  wide  dif- 
ference in  the  clinical  pictures  presented,  but  certainly  not  more  so  than 
there  is  in  epilepsy  or  other  neuroses.     In  this  regard  I  quite  agree  with 


DISORDERS    OF    SLEEP  675 

Putnam,  who  says:  "It  is  hard  to  convince  one's  self  that  there  are  two 
classes  so  definitely  separated  from  each  other.  It  is  true  that  between  two 
individual  cases  there  may  be  a  vast  difference  in  all  the  particulars  men- 
tioned by  Silbermann,  but,  taking  all  cases  together,  the  degrees  of  differ- 
ence are  so  slight  that  it  is  almost,  or  quite,  impossible  to  draw  a  line  of 
demarcation." 

Prognosis. — In  the  symptomatic  form  the  prognosis  is  very  good,  be- 
cause it  is  produced  by  etiological  factors  which  can  readily  be  removed  by 
appropriate  treatment.  In  the  idiopathic  form  the  prognosis  is  not  so  good, 
and  depends  largely  upon  the  gravity  of  the  underlying  hereditary  taint. 
All  of  these  cases,  however,  should  yield  to  appropriate  treatment,  but 
idiopathic  night-terrors  should  call  attention  to,  and  demand  treatment  for, 
the  underlying  hereditary  condition. 

Treatment. — In  beginning  the  treatment  of  all  these  cases  the  in- 
testinal canal  must  be  carefully  scrutinized  and  all  possible  reflex  irrita- 
tion from  tliis  source  removed.  A  preliminary  cathartic  followed  by  a 
carefully  regulated  diet  with  a  light  evening  meal  should  be  a  part  of  the 
treatment  in  every  case.  It  is  impossible  to  lay  too  much  stress  upon  the 
role  which  disorders  of  the  gastrointestinal  canal  play  in  these  cases.  It 
is  incumbent  upon  the  physician,  therefore,  to  thoroughly  satisfy  himself 
that  the  intestinal  canal  of  the  child  is  no  longer  a  source  of  irritation  or 
intoxication  to  the  nervous  system,  and  in  doing  this  he  must  remember 
that  intestinal  toxemia  may  be  present  without  any  pronounced  symptoms 
on  the  part  of  the  gastrointestinal  tract.  Enlarged  tonsils,  adenoids,  and 
nasal  obstructions  of  all  kinds,  as  well  as  all  other  discoverable  causes  of 
reflex  irritation,  should  be  removed. 

The  child's  general  health  should  be  carefully  looked  after.  A  diet 
should  be  selected  with  reference  to  the  character  of  the  malnutrition  pres- 
ent. Tonics  such  as  iron,  arsenic,  cod-liver  oil,  or  malt  containing  diastase 
may  be  indicated  in  individual  cases.  An  outdoor  life,  with  an  abundance 
of  sunshine  and  fresh  air,  is  also  important.  In  the  idiopathic  cases  the 
child's  nervous  system  should  be  as  carefully  shielded  from  mental  strain 
and  nervous  excitement  as  if  it  were  suffering  from  one  of  the  graver  neu- 
roses. The  medical  treatment  consists  in  giving  the  broraids  of  sodium, 
or  potassium,  in  five-  or  ten-grain  doses  at  bedtime.  It  is  best  to  combine 
with  this  a  dose  of  tincture  of  belladonna  suitable  to  the  age  of  the  child 
(one  to  four  minims).  The  bromid  of  potash,  and  belladonna  will,  as  a 
rule,  readily  control  the  paroxysms,  and,  after  four  or  five  nights,  all  seda- 
tive medication  may  cease;  in  severe  cases,  however,  it  may  be  necessary 
to  give  this  prescription  for  weeks  at  a  time. 
-) 

INSOMNIA 

Prolonged  insomnia,  as  it  occurs  in  the  adult,  lasting  through  the 
greater  portion  of  the  night,  is  uncommon  in  children;  when  it  does  occur 
it  is  a  symptom  of  some  more  or  less  serious  disease. 


676  GENERAL  NERVOUS  DISEASES 

Disturbed  or  iinrefreshing  sleep,  with  possibly  a  few  hours  of  wake- 
fulness, is  common  in  childhood,  and  it  is  this  condition,  rather  than  true 
insomnia,  which  here  interests  us. 

Etiology.  ^Disturbed  sleep  is  produced  by  very  much  the  same  etiologi- 
cal factors  as  night-terrors.  A  general  nervous  irritability  is  probably 
the  most  important  underlying  factor;  it  may  be  a  matter  of  heredity,  it 
may  be  produced  by  chronic  malnutrition,  it  may  occur  in  the  convalescence 
from  acute  infections,  and  it  may  be  very  greatly  exaggerated  by  more  or 
less  constant  nervous  excitement.  The  mental  stimulation  and  strain  of 
school  life  with  night  study,  and  the  anxiety  which  sensitive  children  have 
concerning  the  lessons  of  the  following  day,  may  in  older  children  be  causes 
of  disturbed  sleep.  In  infancy  nervous  excitement  is  also  a  cause  of  rest- 
less sleep.  The  habit  of  constantly  entertaining  infants,  and  constantly 
attracting  their  attention,  and  bringing  them  into  the  whirl  and  excitement 
of  the  living-room,  where  they  may.  be  observed  and  commented  upon,  can- 
not be  too  severely  condemned.  Filling  young  minds  with  exciting  stories 
before  they  are  put  to  bed  predisposes  to  dreams  and  disturbed  sleep. 
Lack  of  proper  training  is,  in  the  young  infant,  the  most  potent  of  all 
causes  of  insomnia.  Rocking  them  to  sleep,  lifting  and  fondling  them 
every  time  they  make  an  outcry,  and  feeding  them  at  night  are  causes 
which  produce  insomnia.  Disturbances  of  digestion  are  important  direct 
exciting  causes.  Overfeeding  and  improper  feeding  may  develop  in  the  in- 
testinal canal  important  reflex  and  toxic  factors  which,  by  their  action  on 
the  nervous  system,  may  disturb  sleep.  In  infants  intestinal  fermentation 
may,  by  the  development  of  gases,  produce  colic.  This  may  also  occur  in 
older  children,  but,  as  a  rule,  'Constipation,  with  more  or  less  obscure  in- 
testinal toxemia,  is  with  them  a,  more  important  factor  of  nocturnal  rest- 
lessness. In  very  young  infants  hunger  may  be  a  cause  of  sleeplessness. 
Poorly  ventilated  and  overheated  rooms,  with  lack  of  fresh  air,  heavy  and 
uncomfortable  bed-clothing,  dentition,  otitis,  adenoids,  enlarged  tonsils, 
and  nasal  obstructions  may  cause  restlessness  at  night. 

Varieties. — There  are  two  rather  distinct  types  of  insomnia.  In  one 
the  child  retires,  and,  unlike  the  normal  child,  does  not  fall  asleep  prompt- 
ly. It  rolls  restlessly  in  bed,  very  often  is  tormented  by  frequent  desire  to 
urinate,  betrays  its  sensory  irritability  in  this  manner  and  also  by  its  ex- 
treme sensitiveness  to  even  the  slightest  noises,  such  as  the  ticking  of  a 
clock,  the  creaking  of  the  shutters,  and  the  passing  of  the  street  cars. 
Finally,  after  two  or  three  hours,  it  may  fall  asleep,  but  is  usually  a  so- 
called  "light"  sleeper. 

In  the  other  type  sleep  comes  at  once,  but  the  child  awakens  in  the 
middle  of  the  night,  and  thereafter  is  unable  to  secure  further  sleep.  Here, 
as  in  the  first-named  type,  there  will  often  be  frequent  micturition,  flush- 
ing of  the  skin,  aversion  to  much  bed-covering,  frequent  punctilious  ad- 
justment of  the  bed  and  pillows.  Both  types  may  exhibit  a  tendency  to 
dreams,  pleasant  or  unpleasant,  as  well  as  to  recurring  chains  of  thoughts 
peculiar  to  each  individual. 


DISOKDERS    OF    SLEEP  677 

It  is  unnecessary  to  state  that  such  children  do  not  awaken  "re- 
freshed/' but  are  prone  to  manifest  the  symptom-complex  of  abnormal 
fatigue.  That  the  foundation  for  future  neurasthenia  is  furnished  by 
such  prolonged  sleeplessness  goes  without  saying. 

Treatment. — The  propiiyla.ctic  treatment,  which  should  begin  when 
the  child  is  born,  is  of  the  utmost  importance.  This  consists  in  care- 
fully regulating  the  life  of  the  infant,  shielding  it  from  excitement,  feed- 
ing it  at  regular  intervals,  and  insisting  from  the  beginning  that  the  night 
shall  be  devoted  to  sleep.  It  is  a  comparatively  simple  matter  to  establish 
a  routine  regularity  which  will  firmly  engraft  upon  the  infant  the  habit 
of  sleeping  profoundly  throughout  the  night.  This  habit,  when  once  es- 
tablished and  closely  adhered  to,  will  do  much  to  overcome  the  nervous 
irritability  which  the  infant  may  have  inherited.  As  the  child  grows  older 
this  regularity  in  eating  and  sleeping  should  be  carefully  adhered  to,  and 
the  child  should  be  given  a  light  evening  meal  and  put  to  bed  soon  after- 
ward. 

Treatment  of  the  Condition. — The  treatment  consists  in  attempting 
to  establish  the  regularity,  above  referred  to,  with  which  the  lack  of  proper 
training  has  interfered.  An  effort  should  be  made  to  discover  the  essen- 
tial causes  of  the  sleeplessness.  Disturbances  of  the  intestinal  tract  should 
be  carefully  treated,  and  all  possible  causes  of  reflex  irritation,  whether 
they  occur  in  the  nose,  throat,  or  elsewhere,  should  be  removed.  The  child 
should  sleep  in  a  well-ventilated  and  not  overheated  room,  and  the  bed- 
clothing  should  be  properly  adjusted  to  the  season  of  the  year.  If  it  suffers 
from  cold  feet,  a  warm  bath  at  night  with  a  hot-water  bottle  to  the  feet 
may  assist  in  overcoming  the  sleeplessness.  Shower  baths  are  of  great 
value;  in  winter  the  hot  and  cold  shower  or  spray,  in  summer  a  moderately 
cold  shower.  Overpressure  at  school  and  mental  excitement  of  all  kinds, 
especially  just  before  going  to  bed,  should  be  avoided. 

Insomnia,  occurring  as  an  acute  condition  in  an  otherwise  healthy  in- 
fant, should  lead  one  to  suspect  acute  intestinal  disturbance.  Intestinal 
pain  produced  by  colic  may  be  relieved  by  an  enema,  and  the  child  that 
has  fretted  and  tossed  for  hours  may  fall  asleep. 

The  use  of  medicines  to  promote  sleep  in  children  is  rarely  necessary, 
unless  the  restlessness  is  produced  by  some  acute  febrile  condition.  Bromids 
of  potash  and  sodium  are  perhaps  the  most  justifiable  remedies  under  these 
conditions.  Other  hypnotics,  which  are  so  valuable  in  the  treatment  of 
insomnia  in  the  adult,  are  of  doubtful  value  in  the  child. 

SOMNAMBULISM 

Somnambulism,  or  sleep-walking,  has  very  much  the  same  etiological 
factors  as  night-terrors  and  insomnia. 

The  somnambulist,  soundly  asleep  and  apparently  unconscious,  with 
his  special  senses  in  abeyance,  may  rise,  walk,  or  run  about  in  the  dark, 
avoiding  objects  and  performing  difficult  and  apparently  purposive  acts 


678  GENEKAL  NERVOUS   DISEASES 

quite  as  dextrously  as  he  could  when  awake,  but  when  aroused  from  this 
state  he  is  unconscious  of  what  has  transpired.  Somnambulism  is  not  un- 
commonly observed  in  children,  but  the  marvelously  complicated  movements 
which  have  been  accredited  to  adult  sleep-walkers  have  not  been  noted  in 
the  child.  Children,  however,  may  get  out  of  bed  and  walk  or  run  about 
the  room  in  the  pursuit  of  some  object,  or  with  a  definite  purpose  suggested 
by  a  dream,  which  the  child  is  acting. 

Sleep-talking  may  be  combined  with  sleep-walking.  I  once  witnesi^ed 
a  performance  of  this  kind  in  a  child  seven  years  of  age.  This  child  during 
the  day  had  been  much  interested  in  seeing  his  dog  Towser  catch  and  kill 
rats  as  they  were  one  by  one  liberated  from  a  trap.  In  the  early  hours  of 
the  night  he  sprang  from  bed  and  ran  in  the  dark  through  the  house,  call- 
ing to  his  dog,  "Eats,  Towser,  rats !  Towser,  here  they  are !"  and,  for  some 
minutes,  avoiding  furniture  and  directing  his  movements  with  great  accu- 
racy, he  led  the  chase  until  he  was  finally  captured  by  his  mother,  and  in 
his  half-dazed  state  led  back  to  bed  and  to  sleep.  The  next  morning  he 
knew  nothing  of  the  occurrence.  Earely  somnambulism  may  be  confounded 
with  a  graver  type  of  automatic  subconscious  activity,  the  psychic  equiva- 
lent of  an  epileptic  attack. 

The  treatment  for  this  condition  is  the  same  as  that  above  outlined 
for  Insomnia. 

ECLAMPSIA  IN  INFANTS  AND  CHILDREN 

A  convulsion  is  a  sudden  discharge  of  motor  nerve  force  resulting  in 
violent  and  rapid  muscular  contractions  of  one  or  more  parts  of  the  body. 
It  is  not  a  distinct  disease,  but  a  symptom  group  which  may  be  produced  by 
a  great  variety  of  causes. 

Etiology. — Predisposing  Causes. — Age. — Infants  during  the  first  few 
weeks  of  life  are  comparatively  immune  to  eclampsia,  but  from  the  fourth 
month  to  the  end  of  the  second  year  they  are  especially  predisposed  to  all 
kinds  of  convulsive  disorders.  In  the  third  year  of  life  convulsions  be- 
come less  frequent,  and  from  this  time  on  in  the  normally  developed  child 
they  are  but  slightly  more  common  than  they  are  in  the  adult.  The  ex- 
planation for  the  varying  predisposition  of  the  infant  and  young  child 
to  convulsive  disorders  at  different  periods  of  its  life  can  be  largely  found 
in  the  anatomical  and  physiological  development  of  the  nervous  system. 

The  excitation  of  cerebral  motor  centers  cannot  readily  produce  con- 
vulsive disorders  in  the  very  young  infant,  because  the  discharge  of  nerve 
force  from  these  centers  is  not  readily  communicated  to  the  spinal  reflex 
centers,  since  at  this  early  period  of  life  the  fibers  of  the  pyramidal  tracts 
have  not  fully  developed  their  myelin  sheaths,  and  are  not,  therefore,  ca- 
pable of  readily  transmitting  impulses  from  the  cortical  centers  to  the 
spinal  cells.  The  development  of  these  myelin  sheaths,  however,  gradu- 
ally goes  on,  so  that  the  pyramidal  tracts  have  their  functions  sufficiently 
developed  to  place  the  lower  spinomuscular  neurons  and  the  cerel)ral  mo- 


ECLAMPSIA    IN    INFANTS    AND    CHILDEEN  679 

tor  centers  in  close  touch  by  the  time  the  child  is  three  or  four  months  of 
age.  In  addition  to  this  the  following  peculiarities  of  the  nervous  system 
of  the  young  infant  protect  it  to  a  certain  degree  from  convulsive  disor- 
ders: The  cerebral  motor  areas  at  birth  are  but  poorly  developed  and  do 
not,  therefore,  readily  react  to  excitation.  These  motor  areas,  however, 
are  rapidly  developed;  so  that  early  in  the  life  of  the  infant  they  become 
very  sensitive  to  all  kinds  of  stimulation.  The  reflex  centers  in  the  spinal 
cord  at  birth  are  poorly  developed  and  not  easily  excited,  but  these  cen- 
ters also  become  very  excitable  after  the  third  or  fourth  month  of  life. 
Both  the  sensory  and  motor  peripheral  nerves,  which  are  a  necessary  part 
of  the  reflex  arc  through  which  convulsive  disorders  find  expression,  have 
a  very  low  degree  of  irritability  in  the  newly-born  child.  A  little  later  in 
the  life  of  the  infant  these  nerves  become  hypersensitive.  This  hyper- 
excitability  of  peripheral  nerves  is  much  more  marked  in  some  children 
than  in  others,  and  constitutes  the  spasmophilic  diathesis;  spasmophilia  is 
an  important  predisposing  cause  of  eclampsia,  tetany,  and  perhaps  other 
convulsive  disorders  in  infancy. 

The  most  important  peculiarity  of  the  young  nervous  system  is  the 
comparative  lack  of.  both  automatic  and  voluntary  inhibition,  by  reason  of 
which  higher  nerve  centers  exercise  little  or  no  inhibitory  control  over 
the  lower  convulsive  and  reflex  centers.  Lach  of  inhibition  is  especially 
important,  since  it  continues  to  a  greater  or  less  degree  throughout  infancy 
and  young  childhood;  this  explains  the  comparative  frequency  of  convul- 
sions between  the  fourth  month  and  the  beginning  of  the  third  year,  when 
both  sensory  and  motor  peripheral  nerves  are  very  excitable;  the  cerebral 
motor  centers  are  very  active  and  easily  irritated ;  the  spinal  reflex  centers 
are  easily  excited,  and  the  communications  through  the  pyramidal  tracts 
between  the  cerebral  motor  centers  and  the  spinal  cord  cells  have  become 
very  close  through  the  development  of  the  myelin  sheaths  of  the  fibers  of 
the  pyramidal  tracts.  Later  in  the  life  of  the  child  convulsive  disorders 
are  less  common,  because  the  spasmophilia  has  largely  disappeared  and 
the  whole  nervous  system  is  now  less  irritable  and  more  stable,  and  the 
inhibitory  function  of  the  cortical  over  the  subcortical  and  lower  spinal 
neurons  is  more  firmly  established. 

Heredity  is  a  very  important  predisposing  cause  to  convulsive  disorders. 
Whole  families  of  children  will  be  found  who  have  convulsions  from  very 
slight  causes.  The  child  may  inherit,  from  neurotic  ancestors,  unstable 
and  irritable  nerve  centers  under  feeble  inhibitory  control,  which  predis- 
pose it  to  all  kinds  of  functional  nervous  diseases. 

Rachitis  plays  such  an  important  role  in  the  etiology  of  infantile  con- 
vulsions that  it  is  sometimes  classed  as  a  direct,  rather  than  an  exciting, 
cause.  Eickets  predisposes  to  neurotic  disease  in  general  and  to  convulsive 
disorders  in  particular,  because  it  is  the  most  common  and  the  most  pro- 
found form  of  malnutrition  which  occurs  in  infancy ;  it  acts  by  .exagger- 
ating all  those  physiological  weaknesses  of  the  nervous  system  of  the  in- 
fant   which  may  predispose  it  to  convulsions,  and  as  a  result  an  infant 


680  GENERAL  NEEVOUS   DISEASES 

during  the  second  six  months  of  life,  suffering  from  well-marked  rickets, 
ma}'  have  convulsions  from  causes  so  slight  that  they  ofttimes  cannot  be 
detected.  Other  forms  of  malnutrition  occurring  during  the  convulsive 
age  may  predispose  to  eclampsia.  Among  these  the  following  may  l)e  men- 
tioned: chronic  gastroenteritis,  hereditary  syphilis,  tuberculosis,  scurvy, 
and  anemia. 

Exciting  Causes. — Intestinal  toxins,  usually  of  bacterial  origin,  are 
by  far  the  most  common  exciting  causes  of  convulsive  disorders  in  infants 
under  two  years  of  age.  Acute  systemic  intoxication,  commonly  of  bac- 
terial origin,  is  the  most  frequent  cause  of  convulsions  after  the  second  or 
third  year.  Many  of  the  acute  infectious  diseases,  such  as  pneumonia,  scar- 
let fever,  measles,  poliomyelitis,  cerebrospinal  meningitis,  smallpox,  malaria 
and  whooping-cough,  may  produce  convulsions.  Autointoxications  of  the 
recurrent  vomiting  type  may  rarely  be  ushered  in  by  convulsions.  Uremia 
is  an  important  cause  of  convulsions,  especially  after  the  third  or  fourth 
3^ear  of  life,  and  it  should  always  be  suspected  if  the  child  is  suffering 
from  or  has  recently  had  one  of  the  acute  infectious  diseases,  such  as  in- 
fluenza, scarlet  fever  or  diphtheria.  In  every  convulsive  disorder  the  urine 
should  be  examined.  Insolation  is  a  not  uncommon  cause  of  convulsions 
in  infants.  The  heat  stroke  probably  acts  by  still  further  weakening  the 
feeble  inhibition  of  the  infant.  During  the  first  days  of  life  the  most  com- 
mon causes  of  convulsions  are  cerebral  hemorrhage,  asphyxia,  and  birth 
injuries  to  the  skull  and  brain. 

Reflex  Factors. — While  the  importance  of  reflex  irritation  has  been 
greatly  exaggerated  as  an  exciting  cause  of  eclampsia,  it  should  be  noted 
that  these  factors  are  quite  capable  of  producing  a  convulsive  seizure  in 
highly  neurotic  and  rachitic  infants  having  the  spasmophilic  diathesis. 
In  many  of  these  cases  the  predisposing  causes  are  so  potent  that  the  ex- 
citing causes  may  be  almost  or  quite  overlooked.  Undigested  food,  worms 
and  other  irritants  in  the  intestinal  canal,  and  perhaps  even  the  cutting 
of  a  tooth,  may,  in  highly  predisposed  infants,  be  the  exciting  cause  of 
convulsions.  In  such  cases,  however,  the  exciting  causes  are  so  slight  and 
the  predisposing  causes  so  powerful  that  the  latter  must  be  considered  as 
the  important  factors  in  producing  the  eclampsia. 

Epilepsy. — A  symptom  group  characterized  by  recurring  convulsions 
should  be  suspected  when  convulsions  are  repeated  from  time  to  time  with- 
out apparent  cause.  Convulsions  may  be  produced  by  organic  lesions  press- 
ing on  or  irritating  the  cerebral  motor  centers.  Among  such  causes  may 
be  mentioned  meningeal  hemorrhage,  meningitis,  tumor,  abscess,  hydro- 
cephalus, embolism,  thrombosis,  and  injury  to  the  skull  or  brain.  The 
role,  however,  which  these  organic  lesions  play  in  producing  convulsions  is 
slight  as  compared  with  the  non-organic  factors  previously  noted. 

Symptomatology. — Eclampsia  is  a  syndrome  and  not  a  disease.  This 
symptom  group,  however,  always  indicates  the  existence  of  some  serious 
acute  or  chronic  disease,  the  nature  of  which  must  be  determined  by  other 
symptoms  and  by  the  general  history  of  the  case. 


ECLAMPSIA    IN    INFANTS    AND    CHILDREN  681 

Certain  premonitory  symptoms,  such  as  sudden  twitchings  of  the 
muscles  of  the  arms,  legs,  or  face,  associated  with  high  fever,  may  indicate 
that  eclampsia  is  threatened.  In  many  instances  the  physician  will  be 
called,  not  because  the  patient  has  fever  or  gastrointestinal  disturbance, 
but  because  the  mother  has  become  alarmed  at  the  occasional  sudden  jerk- 
ings  or  spasmodic  contractions  of  the  legs,  arms,  or  face  of  her  sleeping 
child.  It  may  continue  to  toss  restlessly  in  its  sleep  for  a  time,  and  then, 
without  awakening,  pass  into  a  general  convulsion. 

Perhaps  in  the  majority  of  instances  the  convulsive  storm  occurs  with- 
out warning.  A  sudden  pallor  of  the  face  is  followed  by  a  convulsive 
stiffening  of  the  muscles,  the  eyes  roll  up  and  become  fixed,  spasmodic  con- 
tractions of  muscles  occur;  these  clonic  contractions  may  almost  imme- 
diately become  tonic,  producing  rigidity  of  the  entire  body;  the  face  is 
distorted,  the  head  is  drawn  to  one  side,  the  hands  are  clinched  upon  the 
thumbs.  Very  shortly  clonic  convulsive  jerkings  of  the  head  and  extrem- 
ities supervene,  and  these  severe  spasmodic  movements  continue  for  three 
or  four  minutes,  leaving  the  child  relaxed,  exhausted,  and  in  a  condition  of 
more  or  less  profound  sleep,  from  which  it  may  awake  bright  and  conscious, 
or,  without  awakening,  may  pass  into  a  second  convulsion.  The  sleep  whicli 
follows  may  be  of  short  duration,  or  it  may  be  a  true  stupor  or  coma  which 
continues  in  the  interval  between  the  convulsions.  The  number  of  convul- 
sions in  an  individual  case  will  depend  upon  the  character  and  severity 
of  the  disease  of  which  they  are  a  symptom.  There  may  be  but  one  con- 
vulsion, or  convulsions  may  be  repeated  at  short  intervals  over  a  number 
of  days.  In  the  ordinary  eclampsia  of  infancy  the  patient  awakens  from 
the  sleep  which  follows  the  convulsion,  appears  bright,  is  conscious  and 
gives  little  evidence  of  the  severe  nervous  storm  through  which  it  has 
passed.  In  severe  convulsive  seizures  incontinence  of  urine  and  feces  may 
occur,  and  there  may  be  more  or  less  spasm  of  the  respiratory  muscles,  pro- 
ducing a  shallow,  irregular  breathing,  or  a  spasmodic  choking  sound;  cy- 
anosis may  occur  and  life  may  be  threatened  by  asphyxia.  Wliile  uncon- 
sciousness and  spasmodic  muscular  contractions  are  considered  a  neces- 
sary part  of  the  eclamptic  syndrome,  these  convulsive  seizures  may  vary 
greatly  in  severity,  from  a  momentary  unconsciousness  with  slight  twitching 
of  some  portion  of  the  body  to  a  general  convulsion  so  severe  as  to  take 
the  life  of  the  child.  Convulsions  may  involve  a  portion  of  the  body,  or 
they  may  be  general,  or  again  they  may  begin  in  a  certain  group  of  muscles 
and  spread  until  nearly  the  entire  muscular  system  is  involved. 

One  attack  of  eclampsia  does  not  necessarily  predispose  to  another,  un- 
less some  organic  injury  to  the  nervous  system  results  from  the  convulsive 
seizure.  The  same  predisposing  causes,  however,  which  made  possible  the 
first  convulsion  may  account  for  subsequent  attacks  from  slight  exciting 

causes. 

Prognosis. — Age  is  a  very  important  factor  in  prognosis.  In  tbe  new 
born  the  prognosis  is  bad,  because  convulsions  at  this  time  of  life  are  com- 
monly produced  by  asphyxia,  serious  brain  lesions,  or  congenital  defects. 


682  GENERAL  NERVOUS  DISEASES 

and  are,  therefore,  frequently  followed  by  spastic  palsies,  epilepsy,  and 
mental  defects.  Convulsions  occurring  between  the  second  week  and  fourth 
month  of  life,  while  they  are  not  so  ominous  in  their  import  as  those  oc- 
curring during  the  first  week,  yet  they  are,  as  a  rule,  more  serious  than 
those  that  occur  between  the  fourth  month  and  the  end  of  the  second  year. 
At  this  latter  period  convulsions  may  occur  from  comparatively  trivial  and 
easily  removable  causes,  and  the  prognosis  is  on  the  whole  good.  In  older 
children,  especially  after  the  third  or  fourth  year  of  life,  the  prognosis 
again  becomes  more  grave,  since  convulsions  at  this  time  are  commonly  due 
to  uremia  or  to  one  of  the  acute  infectious  diseases.  Apart  from  the  age  of 
the  child,  the  prognosis  may  be  indicated  by  the  severity  of  the  initial  con- 
vulsion; by  the  depth  of  the  supervening  coma;  by  the  continuance  of  lo- 
calized contractures  in  the  interval  between  the  convulsions;  by  the  fre- 
quent occurrence  of  convulsions  without  apparent  exciting  cause,  by  the 
evidence  of  some  injury  to  the  head,  and  by  the  presence  of  cyanosis,  as- 
phyxia, and  spasmodic  breathing.  It  is  well,  however,  for  the  physician  to 
remember  that  even  the  above  prognostic  indications  do  not  furnish  safe 
grounds  for  a  positive  prognosis.  One  should,  therefore,  in  all  cases,  give 
a  guarded  prognosis  and  await  further  developments  to  determine  the 
causes  which  have  produced  the  convulsion,  since  the  character  of  the  dis- 
ease which  produces  the  eclampsia  is  the  most  important  factor  in  prog- 
nosis. Pertussis  and  advanced  rickets  are  among  the  etiological  factors 
which  add  gravity  to  the  prognosis. 

Treatment. — In  the  majority  of  instances  convulsions  are  self-limited 
and  last  such  a  short  time  that  when  the  physician  reaches  the  patient 
the  convulsive  movements  have  ceased.  The  treatment  in  these  milder  cases 
from  the  beginning  is  directed  to  the  prevention  of  subsequent  attacks. 

In  a  small  percentage  of  the  cases,  however,  the  convulsion  itself  is 
a  source  of  danger  not  only  to  life  but  also  to  the  subsequent  well-being  of 
the  child,  and  the  longer  the  convulsion  lasts  the  greater  are  these  dan- 
gers. In  these  cases  the  prime  object  in  the  treatment  is  to  terminate  the 
convulsion  as  soon  as  possible,  regardless  of  its  cause.  This  may  be  done 
by  inhalations  of  chloroform ;  the  convulsive  movements  quickly  cease  when 
a  few  drops  of  chloroform  are  placed  upon  a  handkerchief  and  held  to 
the  child's  nose.  The  administration  of  chloroform  may  be  repeated  from 
time  to  time  for  the  purpose  of  cutting  short  the  return  of  convulsive 
movements,  and  this  treatment  may  be  safely  continued  until  the  convul- 
sive movements  have  been  brought  under  control  by  other  remedies.  As 
soon  as  the  convulsions  have  subsided  under  the  inhalation  of  chloroform 
the  child  is  placed  in  a  bath,  the  temperature  of  which  will  depend  upon 
a  number  of  conditions.  If  the  fever  be  high,  one  should  begin  with  a  luke- 
warm bath  which  is  gradually  cooled  to  80° F.  This  not  only  reduces  the 
body  temperature,  but  exerts  a  soothing  and  tonic  effect  upon  the  nervous 
system.  If,  however,  the  patient  be  very  young  or  very  frail,  the  bath  is 
not  to  be  cooled  below  90°  or  95°F.  Immediately  following  the  bath  an 
ice-cap  should  be  applied  to  the  head ;  it  helps  to  keep  down  the  tempera- 


ECLAMPSIA    IN    INFANTS    AND    CHILDREN  683 

ture  and  acts  as  a  sedative  to  the  nervous  system.  The  bath  and  ice-cap 
are  to  be  used  in  the  subsequent  treatment  of  the  case  if  high  fever,  convul- 
sions, and  other  nervous  symptoms  are  present. 

A  cathartic  should  be  given  as  soon  as  possible  regardless  of  the  cause 
of  the  convulsion.  The  selection  of  the  cathartic  will  depend  upon  the  con- 
dition of  the  child's  stomach.  Castor  oil  is  to  be  preferred  if  the  stomach 
will  retain  it;  a  solution  of  Eochelle  or  Epsom  salts  may  be  substituted 
if  the  stomach  be  very  irritable.  If  these  be  not  retained,  a  quarter  of  a 
grain  of  calomel  may  be  given  every  half  hour  until  two  grains  are  given. 
The  importance  of  cathartic  medication  in  the  treatment  of  infantile  con- 
vulsions does  not  depend  wholly  upon  the  fact  that  gastrointestinal  tox- 
emia is  commonly  pr&sent,  since  even  in  those  cases  which  have  their  origin 
entirely  apart  from  the  intestinal  canal  free  catharsis  quiets  the  nervous 
system  and  prepares  the  patient  for  any  special  dietetic  treatment  that 
may  be  necessary  in  the  subsequent  management  of  the  case.  A  high  rectal 
enema  of  a  pint  or  more  of  physiological  salt  solution  should  be  given  im- 
mediately after  removing  the  child  from  the  bath.  The  object  of  this  treat- 
ment is  to  unload  and  irrigate  the  large  intestine,  so  as  to  remove  any 
possible  sources  of  irritation  and  prepare  it  to  receive  and  retain  sedative 
medicines  which  it  may  not  be  possible  to  give  by  the  mouth. 

Chloral  hydrate  is  the  best  and  safest  of  all  remedies  to  control  con- 
vulsions ;  it  should  be  given  dissolved  in  starch  water  by  high  rectal  enema 
half  an  hour  after  the  colon  has  been  unloaded  by  rectal  irrigation.  The 
dose  per  rectum  for  a  child  of  six  months  is  5  grains  and  for  a  child  of 
two  years  10  grains ;  if  given  by  the  mouth  these  doses  are  to  be  cut  in  half. 
It  is  wise  not  to  risk  upsetting  the  stomach  either  with  food,  stimulants  or 
other  medicines  until  the  initial  cathartic  has  been  retained  a  sufficient 
length  of  time  to  insure  its  action.  If  the  chloral  is  retained  by  rectum 
for  three-quarters  of  an  hour  and  the  convulsive  movements  are  under 
control,  the  physician  may  safely  leave  the  case  for  the  time  being  in  the 
hands  of  a  competent  nurse  with  directions  that  the  injection  of  chloral 
be  repeated  in  one  or  two  hours,  and  thereafter  it  should  be  given  by  the 
mouth  in  such  doses  and  at  such  intervals  as  may  be  indicated  by  the  age 
and  condition  of  the  child.  After  twenty-four  hours  the  dose  of  chloral 
may  be  diminished  in  size  and  bromid  of  potash  in  4-  or  5-grain  doses  com- 
bined with  it;  the  chloral  and  bromid  treatment  should  be  continued  until 
all  danger  of  convulsions  has  passed. 

Morphin  is  the  most  certain  of  all  remedies  for  the  control  of  convul- 
sions A  remedy  like  this,  however,  which  acts  so  powerfully,  should  be 
used  cautiously  and  in  the  proper  dosage.  If  the  chloral  is  not  retained 
by  the  rectum,  or  if  the  convulsion  be  so  severe  that  chloral  fails  to  con- 
trol it  morphin  should  be  given  hypodermically,  in  doses  varying  from 
1/50  of  a  grain  for  a  child  six  months  of  age  to  1/20  of  a  grain. for  a 
child  two  years  of  age.  As  a  rule  only  one  dose  of  morphin  is  necessary, 
and  thereafter  the  convulsive  movements  may  be  controlled  by  other  rem- 
edies     If  in  very  severe  eclampsia,  which  requires  repeated  doses  of  mor- 


684  GENERAL  NERVOUS   DISEASES 

phin  for  the  control  of  the  convulsive  symptoms,  a  prolonged  period  of 
coma  or  unconsciousness  should  follow,  it  is  advisable  to  resort  to  venesec- 
tion followed  by  the  injection  into  the  vein  or  subcutaneous  tissues  of  6  or 
8  ounces  of  sterile  normal  salt  solution,  or  Fischer's  solution  may  be  given 
intravenously  as  noted  under  Acute  Nephritis.  This  treatment,  especially 
in  uremic  poisoning,  is  frequently  followed  by  a  return  of  the  child  to 
consciousness. 

Absolute  quiet  for  the  nervous  system  and  physiological  rest  for  the 
gastrointestinal  canal  are  necessary  during  the  first  few  hours  of  treat- 
ment. Food  and  stimulants  by  the  mouth  should  be  avoided  until  the 
intestinal  canal  has  been  unloaded  and  the  convulsive  movements  are  under 
control.  If,  during  this  time,  the  child's  condition  demands  stimulation, 
subcutaneous  injections  of  normal  salt  solution  (6  to  8  ounces)  may  be 
given  at  intervals  of  twelve  hours. 

Following  catharsis  and  the  control  of  the  convulsions,  water,  barley 
water  and  weak  beef  broth  may  be  given  by  the  mouth,  provided  the  child 
craves  food  or  drink. 

When  the  cause  of  the  eclampsia  has  been  ascertained,  which  may  be 
from  twelve  to  thirty-six  hours  after  the  onset  of  the  first  convulsion,  the 
case  is  to  be  treated  with  reference  to  the  control  of  the  disease  which 
caused  the  convulsions.  If  the  trouble  be  of  intestinal  origin,  as  it  com- 
monly is  in  children  under  two  years  of  age,  then  the  feeding  should  be 
that  of  Acute  Gastroenteric  Infection,  which  is  elsewhere  outlined.  If 
the  trouble  be  due  to  one  of  the  acute  infections,  such  as  pneumonia  or 
scarlet  fever,  the  treatment  for  the  underlying  cause  must  follow.  If 
nutritional  disorders,  such  as  acute  rickets,  be  present,  and  the  exciting 
cause  of  the  convulsion  is  slight,  the  subsequent  treatment  must  be  di- 
rected toward  the  removal  of  the  profound  malnutrition,  which  is  the 
important  factor  in  producing  the  convulsion.  If  uremia  or  other  forms 
of  autointoxication  be  present,  the  proper  treatment  for  these  conditions 
must  be  promptly  instituted.  If  the  eclampsia  be  due  to  organic  disease 
of  the  nervous  system,  the  subsequent  history  of  the  case  must  determine 
the  character  of  the  treatment. 

LARYNGISMUS   STRIDULUS 

{Cerebral  Croup,  Child  Crowing,  Inward  Spasms,  Laryngaspasm) 

Laryngismus  stridulus  is  a  reflex  neurosis  due  to  an  underlying  pro- 
found malnutrition.  It  is  most  commonly  observed  in  foundling  hospitals 
and  similar  institutions  for  the  care  of  infants.  It  is  caused  by  a  spasm 
of  respiratory  muscles  and  especially  of  the  adductor  muscles  of  the  larynx, 
which  results  in  a  sudden  closure  of  the  glottis  and  a  temporary  shutting 
off  of  air  from  the  lungs. 

Etiology. — Acute  rickets  is  recognized  as  the  most  important  etiologi- 
cal factor.  Jacobi  called  attention  to  the  relationship  of  craniotabes  to 
this  condition.     Hereditary  syphilis  may  also  be  an  important  factor.     It 


LARYNGISMUS    STRIDULUS  685 

occurs  most  commonly  between  the  sixth  and  the  eighteenth  month,  and  is 
much  more  frequently  observed  during  the  months  of  January,  February 
and  March  than  other  portions  of  the  year. 

Stomach  indigestion,  enlarged  cervical  or  bronchial  lymph  nodes,  the 
dropping  of  mucus  or  other  foreign  substances  into  the  larynx,  fright, 
anger,  acute  adenoid  and  tonsillar  disease,  and  perhaps  even  the  cutting 
of  a  tooth,  may  be  named  among  the  reflex  causes  which  are  capable  of 
touching  off  a  laryngeal  spasm  in  infants  suffering  from  an  advanced  form 
of  acute  rickets,  hereditary  syphilis,  or  some  other  disease  which  produces 
a  profound  malnutrition  and  excessive  irritability  of  the  nervous  system. 

Symptomatology. — A  neurotic  child  suffering  from  one  of  the  mal- 
nutritions previously  named  may,  with  little  or  no  warning,  be  seized  in 
the  early  hours  of  the  night  with  a  spasm  of  the  glottis,  which  may  com- 
pletely shut  off  inspiration.  As  the  glottis  is  closing,  the  child  sometimes 
in  its  struggles  gives  vent  to  a  strident  noise  produced  by  the  rushing 
in  of  air  before  the  stricture  of  the  glottis  is  complete.  With  the  shutting 
off  of  air  the  child  struggles  for  breath,  its  face  becomes  cyanotic,  its  head 
is  thrown  back,  convulsive  movements  of  the  diaphragm  occur,  its  body 
stiffens,  and  its  life  seems  in  imminent  danger,  when  suddenly  a  loud 
crowing  inspiration  announces  the  fact  that  the  spasm  has  relaxed  and  all 
immediate  danger  is  over.  It  is  the  strident  crowing  sound  that  marks  the 
close  of  the  paroxysm  which  characterizes  the  symptom  group  and  gives 
it  its  name.  Following  this  strident  inspiration  the  child  breathes  rap- 
idly, is  greatly  excited,  cries  and  frets,  and  finally  falls  asleep,  possibly 
to  be  awakened  some  hours  later  with  a  second  attack.  General  convul- 
sions follow  the  laryngeal  spasm  in  one-third  of  the  cases.  Convulsive 
movements  of  the  diaphragm  and  other  respiratory  muscles  are,  as  a  rule, 
a  part  of  the  attack.  Carpopedal  spasm,  which  is  one  of  the  classical  symp- 
toms of  tetany,  is  present  in  one-half  of  the  cases. 

Second  and  third  attacks  almost  always  occur  within  a  few  hours  after 
the  first  attack,  and,  in  severe  cases,  the  child  may  have  a  dozen  or  more 
paroxysms  in  twenty-four  hours.  An  attack  of  laryngismus  stridulus  may 
occur  at  any  time  during  the  day  or  night,  but  the  first  attack  of  the  series 
most  commonly  occurs  during  the  most  profound  sleep  in  the  early  hours 

of  the  night. 

Holding-the-breath-spells  which  occur  in  older  children  are  closely 
allied  to,  but  not  identical  with,  laryngismus  stridulus.  In  this  condition 
tlie  spasm  of  the  larynx  is  usually  brought  on  by  a  fit  of  anger.  Spasms 
of  the  larynx  occur  in  acute  laryngitis,  whooping-cough  and  other  diseases, 
but  the  clinical  pictures  produced  are  quite  different  from  that  of  laryn- 
gismus stridulus. 

Prognosis.— The  prognosis  is  good,  so  far  as  the  paroxysm  is  concerned. 
If  the  underlying  malnutrition  can  be  successfully  treated,  then  the  progno- 
sis, so  far  as  ultimate  recovery  is  concerned,  is  also  good.  Some  of  the  more 
severe  cases  die  from  asphyxia  or  general  convulsions. 

Treatment.— Treatment  of  the  Attack.— The  child  should  be  taken 


686  GENEKAL  NERVOUS  DISEASES 

up.  cold  water  dashed  into  its  face,  and  a  cold  wet  towel  applied  to  its 
chest.  If  this  does  not  relieve  the  paroxysm,  chloroform  may  be  given  l)y 
inhalation.     In  more  desperate  cases  intubation  has  apparently  saved  life. 

Prevention  of  the  Attack. — Following  the  initial  attack  the  child 
for  the  first  twenty-four  hours  should  be  kept  somewhat  under  the  influ- 
ence of  chloral,  1  or  2  grains  every  two  or  three  hours,  according  to  its 
age.  After  the  first  twenty-four  hours,  bromid  of  soda  or  potash  may  be 
substituted  for  the  chloral,  4  or  5  grains  every  four  hours  for  a  period  of 
four  or  five  days;  in  severe  cases  the  bromid  treatment  may  be  continued 
for  weeks  at  a  time. 

Treatment  of  the  Underlying  Causative  Condition. — This  is  all- 
important  and  should  be  followed  up  until  complete  recovery  takes  place; 
to  accomplish  this  may  require  years.  The  special  treatment  indicated  will 
depend  entirely  upon  the  character  of  the  underlying  malnutrition, 
whether  this  be  rickets,  syphilis,  or  tuberculosis;  the  treatment  of  these 
conditions  is  given  in  other  chapters.  The  diet  must  be  carefully  selected 
to  suit  the  age,  digestive  capacity  and  individual  requirements  of  the  pa- 
tient. The  child  should  live  in  the  open  air  and  have  as  much  sunlight 
as  possible ;  cod-liver  oil  and  iron  are  important.  When  it  has  sufficiently 
recovered  from  its  malnutrition,  any  disease  of  the  nose  or  throat  that  may 
exist  should  be  removed  by  appropriate  medical  or  surgical  treatment. 


TETANY  IN  INFANCY  AND  CHILDHOOD 

Tetany  is  a  neurosis  characterized  by  tonic  contractures  of  muscles. 
These  contractures  may  be  intermittent,  but,  as  a  rule,  they  are  persistent 
and  subject  to  exacerbations  at  irregular  intervals.  The  favorite  site  for 
these  contractures  is  the  extremities.  The  muscles  of  the  trunk,  neck  and 
face  may  also  be  affected. 

Etiology. — Tetany  occurs  with  far  greater  frequency  in  Europe  than  it 
does  in  America.  In  infancy  males  are  slightly  more  commonly  affected 
than  females,  the  proportion  being  5  to  4.  Most  of  the  cases  occur  during 
the  winter  and  spring;  this  is  perhaps  due  to  the  presence  of  rickets  and 
other  malnutritions  at  this  period  of  the  year.  About  50  per  cent,  of  re- 
ported cases  are  under  two  years  of  age.  From  this  time  on  it  occurs 
with  decreasing  frequency  throughout  childhood,  but  is  seen  again  with 
greater  frequency  about  the  period  of  puberty;  it  may  occur  at  any  age. 

It  is  believed  that  some  defect  in  parathyroid  metabolism  underlies 
many  conditions  characterized  by  muscle  spasm.  Attention  has  been  called 
to  a  possible  similar  etiologic  relationship  in  tetany,  myotonia  congenita, 
paramyotonia  multiplex,  and  myokymia. 

Chronic  gastrointestinal  toxemia  is  perhaps  the  most  important  etiologi- 
cal factor;  it  is  present  in  nearly  every  case  occurring  during  the  first 
two  years  of  life.  Eachitis  is  present  in  the  majority  of  cases.  The  rickets 
associated  with  tetany,  however,  is  not  commonly  of  a  very  severe  type, 


TETANY  m   INFANCY  AND  CHILDHOOD      687 

and  in  this  particular  it  differs  from  the  rickets  associated  with  laryngismus 
stridulus.  Cases  have  been  observed  to  follow  measles,  typhoid  fever, 
rheumatism,  and  pertussis. 

Eeflex  factors,  such  as  undigested  food,  worms  and  foreign  bodies  in 
the  intestinal  canal,  or  adherent  prepuce  and  adenoid  growths,  may  be 
sufficient  to  excite  a  paroxysm  of  tetany  in  spasmophilic  infants.  The 
predisposing  factors  of  tetany  produce  an  irritability  of  the  motor  periph- 
eral nerves;  this  hyperexcitability  of  motor  nerves  constitutes  in  these  in- 
fants the  spasmophilic  diathesis  which  makes  it  possible  for  slight  exciting 
causes  to  produce  exaggerated  tonic  contractions  of  the  muscles  which  they 
supply. 

The  pathological  changes  in  the  nervous  system  which  are  associated 
with  the  syndrome  of  tetany  as  it  occurs  in  the  young  infant  are  not  defi- 
nitely known.  G.  W.  MacCallum  and  others  have  shown  that  tetany  may 
follow  extirpation  of  the  parathyroid  glands  and  that  the  symptoms  in 
these  cases  may  be  controlled  by  the  administration  of  calcium  salts.  It 
has  been  inferred  from  these  facts  that  some  defect  in  calcium  metabolism 
may  be  etiologically  related  to  tetany.  In  fatal  cases  hemorrhages  into 
the  parathyroids,  hydrocephalus,  hyperemia  and  edema  of  the  brain  and 
inflammation  of  the  meninges  and  other  lesions  of  the  nervous  system  have 
been  found.  These  changes  are,  however,  inconstant  and  it  is  not  believed, 
with  the  possible  exception  of  the  parathyroid  findings,  that  they  have  any 
bearing  on  ordinary  infantile  tetany.  Certain  it  is  that,  whatever  may  be 
the  character  of  the  changes  underlying  infantile  tetany,  they  are,  as  a  rule, 
temporary,  since  the  great  majority  of  cases  terminate  in  complete  recovery. 

The  predisposing  causes  of  infantile  tetany,  whatever  they  may  be  in 
an  individual  case,  always  cause,  as  Escherich  and  von  Pirquet  have  dem- 
onstrated, a  hypertonicity  of  the  peripheral  nerves,  producing  in  them  an 
abnormal  excitability  to  the  galvanic  current  which  causes  the  muscle  group 
supplied  by  the  nerve  to  respond  with  both  cathodal  and  anodal  closing 
contractions  to  less  than  5  milliamperes  of  current.  The  median  nerve  is 
usually  selected  for  this  test.  This  condition  of  peripheral  nerve  excita- 
bility to  low  galvanic  currents  is  present  not  only  in  tetany,  but  in  laryngis- 
mus stridulus,  idiopathic  convulsions  in  infancy  and  other  conditions  char- 
acterized by  muscle  spasm.    It  is  spoken  of  as  the  spasmophilic  diathesis. 

In  children  suffering  from  the  spasmophilic  diathesis,  attacks  of  tetany 
may  be  produced  by  such  reflex  factors  as  undigested  food,  worms,  foreign 
bodies  in  the  intestinal  canal,  adherent  prepuce  and  adenoid  growths  or 
localized  muscle  spasm  may  be  produced  in  them,  as  Erb,  Chvostek  and 
Trousseau  long  ago  pointed  out,  by  various  forms  of  peripheral  nerve  irrita- 
tion. 

Symptomatology. — The  most  notable  symptoms  of  tetany  are  tonic  mus- 
cular contractures,  which  occur  in  almost  any  part  of  the  body ;  the  most 
common  locations  for  these  contractures  are  in  the  forearms,  hands  and 
feet  producing  the  carpopedal  spasms.  The  positions  assumed  by  the 
hands  and  feet  are  characteristic;  the  fingers  are  flexed  at  the  metacarpo- 
43 


688  GENERAL  NERVOUS   DISEASES 

phalangeal  joints,  the  phalanges  are  extended  and  the  thumb  is  drawn 
across  the  palm  of  the  hand.  The  wrist  is  sharply  flexed  on  the  arm,  and 
the  whole  hand  is  drawn  toward  the  ulnar  side.  In  the  more  severe  cases 
the  forearms  are  flexed  on  the  arms  and  pressed  against  the  sides  of  the 
thorax.  In  moving  the  elbow  the  resistance  is  not  so  great,  or  so  painful, 
as  in  moving  the  wrist.  In  milder  cases  the  shoulder  and  elbow  Joints 
are  freely  movable,  while  the  contractures  of  the  wrist  and  hand  are  very 
strong.  The  pedal  spasm  usually  accompanies  the  carpospasm  and  the  con- 
tractures are  usually  symmetrical ;  the  feet  are  extended,  and  the  first 
phalanges  of  the  toes  are  flexed,  the  others  extended.  The  foot  is  curved 
inward  and  the  tendo  Achilles  is  very  tense.  The  knee  and  hip  joints  are 
usually  freely  movable;  in  some  cases  the  thighs  are  adducted.  While  these 
contractures  are  commonly  confined  to  the  forearm,  hands,  and  feet,  it  is 
not  uncommon,  in  more  severe  cases,  especially  those  under  one  year  of 
age,  to  have  contractures  of  muscles  of  the  trunk  and  neck,  producing 
opisthotonos  and  stiffening  of  the  body.  I  have  seen  cases  of  this  kind  in 
whicli  the  infant's  body  remained  rigid  when  lifted  from  the  bed.  In  rare 
instances  the  muscles  of  the  face  and  eyes  are  involved. 

A  paroxysm  of  tetany  may  continue  for  a  few  days,  or  it  may  last  for 
weeks,  and  during  this  time  the  muscular  contractures  are,  as  a  rule,  con- 
tinuous. There  may,  however,  be  periods  in  which  there  is  a  marked  remis- 
sion, or  even  a  short  intermission  of  the  spasm.  When  the  paroxysm  has 
subsided,  the  child,  under  proper  treatment,  as  a  rule,  progresses  slowly  to 
a  satisfactory  recovery.  Relapses,  however,  may  occur  at  variable  inter- 
vals, weeks  or  months  intervening. 

Pain  usually  accompanies  the  spasm;  in  bad  cases  this  may  be  severe 
enough  to  cause  the  child  to  cry  out.  Pain  is  greatly  increased  by  any  at- 
tempt to  move  the  contractured  part,  or  by  stretching  or  pressing  on  the 
contractured  muscle.  There  is  no  loss  of  consciousness  in  this  disease, 
unless  general  convulsions  supervene;  this  complication  is  much  less  com- 
mon in  tetany  than  it  is  in  laryngismus  stridulus.  Edema  of  the  feet, 
ankles  and  wrists  may  be  present. 

The  increased  nerve  and  muscle  irritability  finds  expression  in  increased 
electrical  excitability  of  both  nerves  and  muscles  with  changes  in  their 
qualitative  reaction  to  galvanism  (Erb),  (neurotonic  reaction).  It  is  also 
shown  in  the  facial  phenomena  known  as  "Chvostek's  symptom,"  in  which 
spasm  of  the  facial  muscles  is  produced  by  percussing  over  the  facial 
nerve,  and  in  "Trousseau's  symptom,"  where  spasm  of  the  feet  and  hands 
is  greatly  exaggerated  by  pressure  upon  the  large  nerve  trunks  leading  to 
these  extremities;  also  Hoffman's  sign,  an  increased  mechanical  and  elec- 
trical excitation  of  the  sensory  nerves.  These  phenomena,  due  to  increased 
excitability  of  the  peripheral  nerves,  may  be  observed  not  only  during  the 
acute  paroxysm,  but  may  be  also  elicited  in  many  cases  for  some  time  after 
the  muscular  contractures  have  disappeared.  So  long,  therefore,  as  Erb's, 
Trousseau's,  Chvostek's  and  Hoffman's  phenomena  can  be  elicited,  the  pa- 
tient is  not  to  be  considered  as  thoroughly  convalescent  from  the  attack. 


NYSTAGMUS  689 

The  danger  of  second  and  third  attacks  or  relapses  is  not  removed  until 
the  underlying  intestinal  disease  and  malnutrition  have  been  cured. 

An  elevation  of  temperature  of  two  or  three  degrees  is  almost  always 
present.  This  is  perhaps  due  in  part  to  the  underlying  toxemia.  When 
the  intestinal  canal  has  been  unloaded  and  careful  feeding  instituted,  the 
temperature  may  fall  to  normal  and  remain  so,  even  though  symptoms  of 
tetany  may  remain. 

Differential  Diagnosis. — Tetany  is  to  be  differentiated  from  tetanus  by 
the  locations  of  the  contractures  and  by  their  intermittency,  and  especially 
by  the  absence  of  trismus.  Trousseau's,  Erb's,  and  Chvostek's  symptoms 
are  absent  in  tetanus.  The  age,  previous  history  and  general  condition  of 
the  child  will  materially  assist  in  the  differential  diagnosis. 

Treatment. — Calomel  followed  by  castor  oil  will  serve  the  purpose  of 
removing  irritating  and  poisonous  materials  from  the  intestine  and  will  pre- 
pare the  patient  for  the  very  careful  dietetic  treatment  that  is  to  follow. 
The  child  must  be  fed  with  a  view  not  only  to  correcting  the  existing  mal- 
nutrition, but  also  to  preventing  further  intestinal  intoxication.  This 
should  be  done  along  the  lines  detailed  in  the  chapter  on  Chronic  In- 
testinal Indigestion.  For  the  control  of  the  spasm,  chloral  and  bromids 
may  be  used  in  moderate  doses.  Lukewarm  baths,  two  or  three  times  a 
day,  will  not  only  help  in  the  relief  of  the  spasm,  but  will  benefit  the  in- 
testinal condition.  The  child  should  be  given  sunlight  and  fresh  air; 
these  are  almost  as  necessary  in  the  treatment  of  tetany  as  they  are  in 
tuberculosis.  The  patient  should  be  kept  as  quiet  as  possible  and  protected 
from  noises  and  reflex  causes  of  irritation.  As  the  child  improves,  cod-liver 
oil  and  iron  are  of  great  value  in  overcoming  the  malnutrition.  A  careful 
search  should  also  be  made  for  every  possible  cause  of  reflex  irritation..  The 
prepuce  and  rectum  should  be  examined,  and,  as  the  child  convalesces,  the 
throat  and  nose  should  be  inspected.  The  removal  of  reflex  factors  may 
facilitate  recovery.  Calcium  lactate  in  3-  to  5-grain  doses  may  be  tried  if 
the  tetany  does  not  yield  in  a  few  days  to  the  dietetic  treatment  above 
outlined. 

NYSTAGMUS  AND  ASSOCIATED  MOVEMENTS  OF  THE  HEAD 

IN  INFANTS 

W.  B.  Hadden,  under  the  title,  "Head-nodding  and  Head-jerking  in 
Children,  Commonly  Associated  with  Nystagmus,"  described  a  not  uncom- 
mon neurosis  characterized  by  rotary,  lateral,  or  vertical  movements  of 
the  head,  usually  associated  with  rotary,  lateral,  or  vertical  movements  of 

the  eyes. 

Character  of  the  Movements.— Peterson  described,  under  the  term 
"gyrospasms,"  a  rotary  movement  of  the  head  from  right  to  left  and  left 
to  right.  These  head  movements  may  also  take  the  form  of  "head-nod- 
ding" ;  in  these  cases  the  head  moves  with  a  vertical  nodding  motion.  In 
other  cases  the  movements  of  the  head  are  horizontal.     These  vibratory 


690  GENEKAL  NERVOUS  DISEASES 

movements  are,  as  a  rule,  rhythmical  and  rapid,  two  or  three  vibrations  oc- 
curring to  the  second.  The  same  movements,  however,  do  not  always  per- 
sist; any  one  may  be  replaced  by  or  alternate  with  either  of  the  others, 
or  the  three  movements  of  the  head,  vertical,  horizontal,  and  rotary,  may 
all  occur  at  different  times  in  the  same  patient.  Hadden  says  that  piire 
nodding  is  rare,  but  this  movement  is  commonly  combined  with  or  alter- 
nates with  the  lateral  or  rotary  movements.  In  some  cases  these  movements 
may  cease  when  the  child's  attention  is  firmly  fixed  on  some  object,  but, 
as  a  rule,  they  are  increased  when  the  child  is  under  observation.  During 
sleep  the  movements  cease,  and  they  are  not  so  well  marked  and  commonly 
disappear  when  the  child  is  lying  down  and  quiet  in  a  darkened  room,  and 
they  may  sometimes  cease  when  the  eyes  are  covered. 

Nystagmus  is  commonly  associated  with  these  head  movements ;  the  eye 
movements  may  be  rotary,  vertical,  or  lateral.  The  movements  of  the 
eyes,  however,  are  more  rapid  than  the  movements  of  the  head,  the  vibra- 
tions in  some  instances  being  as  rapid  as  six  to  the  second.  These  invol- 
untary vibrations  of  the  eye  are,  as  a  rule,  rhythmical.  The  horizontal 
movement  is  the  most  common,  but  it  may  alternate  with,  or  be  replaced 
by,  vertical  or  rotary  movements,  and,  rarely,  according  to  Mills,  "the 
vertical  and  horizontal  oscillations  may  alternate  regularly  or  irregularly, 
or  a  vertical  movement  may  be  present  in  one  eye  and  a  horizontal  in 
another.  The  commonest  form  of  nystagmus  is  that  in  which  the  move- 
ment is  bilateral,  horizontal,  and  consentaneous." 

The  movements  of  the  head  and  eyes  do  not  always  correspond.  Any 
form  of  eye  movement  may  be  combined  with  any  form  of  head  movement ; 
for  example,  head-nodding  may  be  combined  with  lateral  nystagmus,  or  we 
may  have  nystagmus  of  one  eye  associated  with  any  form  of  head  move- 
ment. In  short,  any  number  of  combinations  of  the  various  head  move- 
ments and  eye  movements  are  possible,  but  it  should  be  remembered  that 
in  perhaps  a  majority  of  cases  the  head  and  eyes  move  in  the  same  direc- 
tion. The  various  head  movements  above  described,  while  commonly  asso- 
ciated with  nystagmus,  may  occur  without  the  nystagmus,  and,  on  the 
other  hand,  the  nystagmus  may  occur  without  the  head  movements. 

Etiology. — This  syndrome  usually  occurs  during  the  first  year  of  life, 
commonly  between  the  second  and  twelfth  months.  During  the  second  year 
of  life  it  is  not  infrequent,  but  after  that  it  is  very  uncommon,  except  as 
it  is  associated  with  ocular  defects,  organic  disease  of  the  nervous  system, 
insanity,  or  congenital  idiocy.  In  this  chapter,  however,  we  are  interested 
only  in  this  syndrome  as  a  manifestation  of  a  not  uncommon  neurosis, 
which  occurs  almost  exclusively  between  the  beginning  of  the  third  and 
the  end  of  the  twentieth  month  of  life. 

Heredity  is  an  important  predisposing  factor.  In  many  of  the  cases 
there  is  a  bad  neurotic  family  history;  epilepsy,  chorea,  hysteria,  and  other 
neuroses,  which  are  characterized  by  feeble  inhibition,  have  been  noted. 
Eachitis  and  gastrointestinal  disease,  with  improper  food,  impure  air,  and 
bad  hygienic  surroundings,  are  very  important  predisposing  causes. 


EPILEPSY  691 

Prognosis. — The  prognosis  is  commonly  good.  This  syndrome,  how- 
ever, in  one  or  more  of  its  manifestations  may  continue  for  months,  but 
under  proper  care  recovery  finally  occurs.  The  head  movements,  as  a  rule, 
disappear  before  the  nystagmus. 

In  making  the  prognosis  in  an  individual  case  it  is  important  that  the 
neuroses  above  described  be  carefully  differentiated  from  the  same  head 
and  eye  movements  occurring  in  certain  organic  diseases  of  the  brain,  as 
well  as  these  same  movements  occurring  with  the  so-called  imperative  move- 
ments of  defective  children.  These  imperative  movements  in  feeble-minded 
children  very  commonly  take  the  form  of  a  salaam,  or  repeated  movements 
of  the  arm,  trunk  or  leg.  If  such  movements  as  these  are  associated  with 
the  syndrome  under  discussion,  the  prognosis  is  not  so  good. 

Treatment.  ^The  treatment  is  largely  a  matter  of  improving  the  child's 
general  nutrition.  Eachitis  and  the  underlying  gastrointestinal  disease, 
if  present,  must  be  treated  by  diet  and  proper  medication.  A  carefully 
selected  diet,  suitable  to  the  age  and  digestive  capacity  of  the  child,  is 
absolutely  necessary ;  fresh  air  and  wholesome  hygienic  surroundings  should 
be  insisted  upon.  Cod-liver  oil  and  some  palatable  and  easily  assimilated 
preparation  of  iron  may  be  of  value.  Under  this  treatment  the  child's 
malnutrition  gradually  disappears,  the  nervous  centers  are  better  nourished, 
become  less  irritable,  and  the  inhibitory  centers  of  the  cortex  gradually 
assume  more  perfect  control  of  the  lower  centers,  and,  as  a  result,  the  syn- 
drome disappears. 

Sedative  medication  may  be  indicated  in  beginning  the  treatment  of 
some  of  these  cases.  Bromids  may  be  given  in  from  3-  to  5-grain  doses 
three  or  four  times  in  twenty-four  hours,  but  they  should  be  discontinued 
unless  there  is  evidence  that  they  are  of  decided  value. 

EPILEPSY 

Definition.— The  syndrome  which,  regardless  of  its  etiology  we  call 
epilepsy  is  characterized  by  habitually  recurring  attacks  of  loss  of  con- 
sciousness and  loss  of  motor  coordination,  which  commonly  find  expres- 
sion in  convulsive  seizures  either  local  or  general. 

Etiology.— Epilepsy  is  produced  by  a  variety  of  pathological  conditions. 
It  may  be  organic,  due  to  some  defect,  disease,  or  injury  of  the  nervous 
system,  or  it  may  be  idiopathic,  due  to  reflex  toxic,  constitutional  or  heredi- 
tary factors,  the  influence  of  which  is  not  clearly  evident. 

'^Age  is  an  important  etiological  factor.  The  vast  majority  of  these 
cases  begin  during  childhood,  and  in  a  considerable  percentage  the  early 
symptoms  are  manifest  during  the  flrst  year  of  life. 

Ilereditij  as  a  predisposing  factor  is  present  in  one-sixth  of  all  cases, 
and  in  one-third  of  those  in  which  there  is  no  evidence  of  organic  disease 
of  the  nervous  system.  The  family  history  may  show  epilepsy,  infantile 
eclampsia,  hysteria,  insanity,  migraine,  or  some  other  well-marked  neurotic 
tendency;  or  there  may  be  a  history  of  hereditary  syphilis. 


692  GENERAL  NERVOUS  DISEASES 

Chronic  malnutritions,  especially  those  produced  b}^  rickets,  chronic 
gastrointestinal  disorders,  and  chronic  heart  disease,  may  be  etiological  fac- 
tors. Autointoxications,  especially  of  the  migrainous  type,  may  aissist  in 
the  production  of  epilepsy;  the  association  of  migraine  and  epilepsy  is 
noted  by  all  authors;  in  these  cases  there  is  commonly  a  family  history  of 
gout  or  of  the  arthritic  diathesis. 

Reflex  irritation,  although  perhaps  not  the  most  important  causative 
factor,  is  closely  associated  with  the  development  of  many  cases  of  epilepsy, 
and  once  the  epileptic  habit  has  been  formed  reflex  irritation  is  one  of 
the  most  common  factors  in  precipitating  attacks.  Abnormal  conditions 
in  the  intestinal  canal,  the  eye,  the  nose,  the  throat,  and  the  genitourinary 
organs  are  the  most  common  causes  of  reflex  irritation.  Teething  has  also 
been  mentioned  as  a  reflex  factor. 

Organic  epilepsy  has  as  its  essential  pathological  factor  some  organic 
disease  of  the  nervous  system,  such  as  agenesis,  porencephalia,  microcepha- 
lus  cysts  formed  by  a  softening  of  the  brain  substance  secondary  to  obstruc- 
tion of  blood  vessels,  tumors  of  the  brain  and  cord,  traumatism  producing 
fracture  of  the  skull,  and,  most  important  of  all,  cerebral  hemorrhages, 
especially  minute  punctate  forceps  injuries  occurring  as  one  of  the  acci- 
dents of  birth,  or  traumas  resulting  from  severe  convulsions,  or  injury  to 
the  head  in  very  early  infancy.  It  had  long  been  known  that  these  in- 
juries to  the  brain  were  responsible  for  a  large  number  of  epilepsies,  but 
a  new  interest  was  added  to  this  subject  by  the  admirable  clinical  studies 
of  B.  Sachs,  who  demonstrated  that  many  obscure  epilepsies  developing  in 
late  childhood  were  focal  epilepsies  having  their  origin  in  cortical  hemor- 
rhages, which  occurred  in  infancy  during  or  shortly  after  birth.  In  many 
of  these  eases  epilepsy  develops  when  the  only  remaining  signs  of  the  spas- 
tic palsy,  which  the  original  lesion  produced,  are  increased  reflexes  and 
unilateral  muscular  weakness. 

Symptomatology. — Grand  mal  is  the  most  important  clinical  type  of 
epilepsy.  It  is  characterized  by  a  sharp  cry,  loss  of  consciousness,  a  fall, 
and  tonic  convulsive  movements  quickly  succeeded  by  general  clonic  con- 
vulsions. The  convulsive  movements  last  for  a  few  minutes,  and  are  fol- 
lowed by  a  more  or  less  profound  sleep,  from  which  the  patient  awakens 
convalescent  from  the  attack,  and  with  little  or  no  knowledge  of  what  has 
happened.  • 

Petit  mal,  or  the  minor  attacks,  is  characterized  by  sudden  loss  of 
consciousness  of  short  duration,  sometimes  only  momentary,  and  by  slight 
local  convulsive  movements,  which  may  be  confined  to  the  fingers  or  face; 
these  movements  are  often  so  slight  as  to  escape  attention.  The  patient 
recovers  himself  almost  immediately  and  is  usually  conscious  that  an  in- 
terval of  unconsciousness  has  passed. 

Between  grand  mal  and  petit  mal,  which  represent  the  extreme  types 
of  epilepsy,  we  may  have  great  variations  in  the  severity  of  the  de- 
gree of  unconsciousness  and  of  the  convulsive  movements,  and  these 
gradations,  together  with  the  less  characteristic  symptoms  that  mark  the 


EPILEPSY  693 

individual  attacks,  give  great  variety  in  symptom  grouping  to  epileptic 
seizures. 

Jacksonian  Epilepsy. — In  these  cases  there  is  an  unilateral  lesion  of 
the  central  nervous  system  which  may  or  may  not  be  evidenced  by  hemi- 
plegia, increased  reflexes,  or  a  weakness  of  the  muscles  of  one  side  of  the 
body.  The  distinctive  characteristic  of  this  type  is  a  monospasm  wliich 
may  later  become  hemilateral  or  even  general.  The  spasm  commonly  be- 
gins in  a  local  muscle  group,  either  in  the  hands  or  face.  It  may  be  lim- 
ited to  this  nmscle  group,  or,  as  is  usually  the  case,  it  may  extend  to  one- 
half  the  body,  or  may  result  in  general  convulsions.  There  is,  as  a  rule, 
no  initial  loss  of  consciousness,  and  consciousness  may  even  remain  unim- 
paired throughout  the  attack,  except  where  severe  general  convulsions  su- 
pervene. 

Nocturnal  epilepsy  occurs  during  sleep  and  may  not  manifest  itself 
during  waking  liours.  Feeble  inhibition  is  an  important  factor  in  pro- 
ducing this  type,  the  convulsions  occurring  when  voluntary  inhibition  is 
lost  in  sleep.^ 

Frecursive  epilepsy  occurs  only  in  childhood.  The  symptoms,  usually 
of  the  "petit  mal"  type,  are  associated  with  involuntary  running  move- 
ments. 

Psychic  epilepsy  is  very  uncommon  in  the  child.  It  is  characterized  by 
sudden  loss  of  consciousness,  the  patient  remaining  motionless  for  a  few 
seconds.  It  is  not  associated  with  convulsive  movements  or  other  symp- 
toms of  epilepsy. 

Numbei-  of  AitacTcs. — The  habitual  recurrence  of  attacks  similar  to 
those  noted,  stamps  the  condition  as  epilepsy.  The  number  of  attacks,  how- 
ever, may  vary  greatly  in  individual  cases.  Many  may  occur  in  twenty-four 
hours,  or  an  interval  of  days,  weeks  or  months  may  elapse  between  them. 

Aura. — The  aura  includes  the  warning  symptoms  which  foretell  the 
impending  attack.  In  focal  or  organic  epilepsy  of  the  Jacksonian  type 
the  aura  is  usually  a  local  spasm  in  a  special  muscle  group  of  the  face, 
arm  or  leg;  sensory  disturbances  may  precede  or  supervene  in  the  affected 
parts,  and  the  local  spasm  is  apt  to  be  converted  into  an  unilateral  or 
general  convulsion.  In  toxic  epilepsy  the  aura  may  be  vertigo,  hemianopsia, 
or  light  and  dark  spots  or  flashes  of  light  before  the  eyes.  In  idiopathic 
epilepsy  there  may  be  so-called  sensory  aura  due  to  irritation  of  the  cor- 
tical zones  of  special  sense,  such  as  a  vague  sensation  in  the  stomach,  a  feel- 
ing of  numbness  or  tingling  in  the  extremities,  general  restlessness,  irri- 
tability of  temper,  aphasia,  or  ocular  or  auditory  phenomena. 

Loss  of  consciousness,  which  is  the  most  characteristic  symptom  of  the 
epileptic  attack,  has  strange  variations  in  its  manifestations.  In  certain 
cases  dream-like  states  with  partial  loss  of  consciousness  may  immediately 
precede  or  follow  the  attack.  In  petit  mal  the  loss  of  consciousness  is  often 
so  slight  that  the  attacks  are  mistaken  by  the  laity  for  dizziness,  fainting 
turns^  or  conscious  tricks.  In  grand  mal  the  unconsciousness  is  profound 
and  unmistakable. 


694  GENERAL  NERVOUS  DISEASES 

The  convulsion,  which  is  the  next  most  characteristic  symptom  of  the 
epileptic  attack,  varies  greatly  in  severity  and  cliaracter.  It  may  be  so 
violent  as  to  cause  painful  bruises  and  other  serious  injuries,  or  so  slight 
that  the  momentary  twitchings  of  the  muscles  of  the  face  or  hands  may 
not  be  observed  at  all. 

Mental  Symptoms. — In  nearly  all  cases  of  epilepsy  there  are  more  or  less 
nervous  irritability  and  mental  impairment ;  in  the  psychic  and  toxic  forms, 
however,  this  may  be  scarcely  noticeable.  In  organic  epilepsy  the  mental 
symptoms  will  depend  upon  the  location  and  extent  of  the  organic  disease. 
Well-marked  mental  impairment  is  the  rule,  and  idiocy  is  not  uncommon. 
In  idiopathic  epilepsy  there  is  retardation  of  mental  development,  so  that 
the  child  may  be  considered  backward  or  mentally  deficient.  In  some 
instances  there  may  be  a  peculiar  cunning  which  enables  the  epileptic  to 
commit  acts  of  violence  and  so  cover  his  tracks  as  to  avoid  suspicion.  In 
the  most  aggravated  cases  a  condition  of  status  epilepticus  or  rarely  hemi- 
epilepticus  may  result;  it  is  characterized  by  frequent  paroxysms,  coma, 
exhaustion,  elevation  of  temperature,  rapid  pulse  and  increased  respiratory 
movements.    These  cases  may  terminate  fatally. 

Diagnosis. — Grand  mal  may  be  confused  with  hysteria,  but  in  this  lat- 
ter condition  the  warning  cry  is  absent;  the  loss  of  consciousness  is  not, 
as  a  rule,  absolute;  the  pupils  are  not  dilated;  the  e3'es,  instead  of  being 
turned  upward  and  inward,  stare  into  vacancy;  there  is  no  involuntary 
passage  of  urine  and  feces,  and  the  narcotism  following  the  attack  is  ab- 
sent. In  the  diagnosis  of  petit  mal  there  is  more  difficulty,  since  the  mother 
may  not  accurately  describe  these  attacks.  Special  importance  in  these 
cases  must,  therefore,  be  attached  to  the  marked  change  in  temperament 
and  increased  irritability,  which  have  occurred  since  these  attacks  made 
their  appearance. 

Great  importance  attaches  to  the  differential  diagnosis  of  the  various 
types  of  epilepsy.  Organic  or  focal  epilepsy  is  frequently  mistaken  for 
the  idiopathic  form,  unless  the  physician  in  every  case  makes  a  careful 
search  for  organic  disease  of  the  nervous  system.  If  Sachs'  advice  be 
followed  to  test  in  every  case  the  comparative  strength  of  the  muscles  of 
the  right  and  left  hand,  and  search  for  an  exaggeration  of  deep  reflexes, 
and,  in  older  children,  for  the  Babinski  sign,  as  well  as  inquire  carefully 
into  the  early  history  of  the  child  for  evidences  of  cerebral  hemorrhage 
or  other  disease  of  the  nervous  system,  many  cases  that  have  been  classed 
as  idiopathic  will  be  found  to  be  organic.  Partial  convulsions,  which  may 
or  may  not  become  general,  persistent  headaches,  and  optic  neuritis  may 
indicate  organic  epilepsy.  Nocturnal  epilepsy  may  exist  unsuspected  for 
a  long  time.  In  these  cases  the  following  s3'mptoms  occurring  during  the 
night  are  significant:  biting  the  tongue,  producing  blood  on  the  pillow, 
and  incontinence  of  urine  and  feces,  followed  the  next  morning  by  lassi- 
tude, mental  dullness,  and  headache. 

Prognosis. — About  10  per  cent,  of  all  cases  of  epilepsy  get  well  under 
proper  treatment.    In  organic  epilepsy  the  prognosis  is  unfavorable,  unless 


EPILEPSY  695 

early  operative  interference  is  resorted  to;  a  few  of  these  eases,  however, 
due  to  syphilis,  are  improved  by  antisyphilitic  treatment.  In  toxic  epilepsy 
of  short  duration  the  prognosis  is  much  better.  In  idiopathic  epilepsy  the 
prognosis  is  more  favorable  when  the  disease  has  lasted  but  a  short  time, 
and  the  interval  between  the  attacks  is  of  long  duration,  and  where  a  po- 
tent and  removable  reflex  factor  is  found,  such  as  eye-strain. 

Treatment. — Where  the  aura  precedes  the  attack  a  sufficient  length  of 
time  to  permit  of  treatment,  inhalations  of  chloroform,  or  nitrate  of  amyl, 
may  shorten  or  prevent  the  attack.  During  the  seizure  some  foreign  body 
should  be  placed  between  the  teeth  to  prevent  injury  to  the  tongue,  but  no 
attempt  should  be  made  to  forcibly  restrain  the  violent  spasmodic  move- 
ments. 

General  Treatment. — Some  epileptics  may  be  favorably  influenced 
by  suggestion;  this  may  be  a  matter  of  environment  or  of  medical  or  sur- 
gical treatment.  Temporary  improvement  very  commonly  follows  almost 
any  radical  change.  Surgical  operation,  change  of  locality,  or  any  new  and 
promising  line  of  treatment  may  lengthen  the  interval  between  the  attacks 
to  months,  in  cases  where  the  interval  has  been  days  or  weeks.  In  the  be- 
ginning it  is  important  that  a  careful  search  should  be  made  for  reflex 
factors.  Eye-strain  should  receive  special  attention,  and  diseases  of  the 
nose,  throat  and  genitourinary  organs  should  be  removed  by  proper  sur- 
gical and  other  measures. 

In  every  case  it  is  absolutely  necessary  to  carefully  study  the  func- 
tions of  the  gastrointestinal  canal.  Chronic  indigestion  and  intestinal  tox- 
emia are,  in  a  large  percentage  of  cases,  important  factors  in  aggravating 
the  epileps}'.  Constipation  must  be  overcome,  and  the  diet  of  the  patient 
should  be  selected  with  reference  to  his  age,  idiosyncrasies  and  digestive 
capacity;  careful  feeding  in  selected  cases  may  accomplish  more  than  any 
form  of  medication.  In  all  cases,  alcohol,  coffee,  tea,  sweets,  salads,  pastry, 
and  an  excess  of  albuminous  food  must  be  avoided.  In  young  children  it 
is  frequently  necessary  to  diminish  the  quantity  of  fats,  giving  skimmed 
rather  than  whole  milk. 

A  careful  routine  in  the  daily  life  of  the  child  should  be  insisted  upon. 
It  should  go  to  bed  early  and  at  a  regular  hour ;  fresh  air  day  and  night 
is  important,  and  exercises  suitable  to  the  individual  case  should  be  pre- 
scribed. A  quiet  country  life,  free  from  noise  and  nervous  irritation,  is 
advisable.     In  mild  cases  mental  training  should  be  given  at  home,  but 

not  at  school. 

Chronic  malnutrition  and  anemia,  whether  produced  by  tuberculosis, 
rheumatism,  heart  disease,  malaria,  disease  of  the  digestive  organs,  heredi- 
tary syphilis,  or  attacks  of  influenza,  or  other  acute  infections,  should  re- 
ceive appropriate  treatment. 

Medical  Treatment. — The  bromid  of  potassium  is  the  most  valuable 
remedy  we  have  in  epilepsy.  It  is  not  simply  palliative,  but  when  combined 
with  the  general  treatment  above  noted  it  may,  in  selected  cases,  be  cura- 
tive.    The  curative  effect  of  the  bromids  is  probably  dependent  upon  the 


696  GENERAL  NERVOUS   DISEASES 

fact  that  the  epileptic  habit  is  interrupted,  in  that  the  irritability  of  the 
cortical  sensory  centers  is  distinctly  lessened,  thus  giving  the  child  an 
opportunity  to  so  improve  under  the  general  treatment  that  after  a  time 
the  bromids  may  be  discontinued  without  causing  a  return  of  the  epileptic 
attacks.  In  the  early  treatment  of  these  cases  from  30  to  60  grains  of 
the  bromid  may  be  used  in  twenty-four  hours,  the  object  being  to  care- 
fully graduate  the  dose,  so  that  the  paroxysm  may  be  controlled  without 
producing  acne,  gastrointestinal  disturbances,  and  the  general  depression 
which  may  follow  excessive  doses.  When  the  minimum  dose  of  bromid  has 
been  found  which  will  control  the  epileptic  seizures,  this  dose  should  be 
continued  for  a  year  or  more,  and  then  gradually  diminislied  during  the 
second  and  third  year.  In  nocturnal  epilepsy  a  large  dose  of  bromid  should 
be  given  at  bedtime. 

The  following  drugs  are  also  recommended  in  epilepsy:  opium,  tinc- 
ture of  belladonna,  chloral,  arsenic,  and  digitalis;  the  latter  is  indicated 
only  when  there  is  a  complicating  cardiac  disease.  Cannabis  indica  is  of 
decided  value  in  epilepsy  associated  with  migraine.  A  warm  alkaline  bath 
followed  by  an  alcohol  rub  exercises  a  sedative  and  favorable  influence  in 
many  cases. 

Surgical  Treatment. — The  surgical  treatment  has  been  on  the  whole 
disappointing,  because  the  favorable  cases  do  not  fall  into  the  surgeon's 
hands  early  enough  to  give  the  best  results.  Sachs  very  clearly  sums  up 
our  knowledge  of  this  subject  as  follows:  "In  a  case  due  to  a  traumatic 
or  organic  lesion  an  early  operation  may  prevent  the  development  of 
cerebral  sclerosis.  If  early  operation  is  not  done  the  occurrence  of  epilepsy 
is  a  warning  that  secondary  sclerosis  has  been  established,  and  an  opera- 
tion may  prevent  it  from  increasing.  Operation  must  include  the  removal 
of  the  diseased  area ;  here,  if  all  other  parts  are  normal,  a  cure  may  result. 
Under  favorable  conditions  a  few  cases  of  epilepsy  may  be  cured  by  sur- 
gery, and  many  more  improved.  ...  I  consider  it  important  not  to 
await  the  actual  development  of  epilepsy;  and  if  the  brain  has  sustained 
any  considerable  injury,  to  remove  the  injured  tissues,  which,  if  allowed 
to  remain,  constitute  a  permanent  menace  to  the  future  health  of  the 
patient.  We  shall  be  able  to  prevent  the  development  of  epilepsy  very 
much  more  readily  than  we  can  cure  it  if  once  established." 

CHOREA 

(Sydenham's  Chorea,   St.    Vitus'   Dance,   Chorea  Minor,   St.   Anthony's 

Dance) 

This  condition  must  be  differentiated  from  habit  spasm,  organic 
chorea,  and  electrical  chorea. 

Definition. — Chorea  is  a  syndrome  occurring  cliiefly  in  cliildren,  char- 
acterized by  involuntary,  inconstant,  incoordinate,  jerky,  and  purposeless 
muscular  movements  involving  a  part  or  all  of  the  voluntary  muscles  and 
occurring  only  when  the  patient  is  awake. 


CHOREA  697 

Etiology. — Predisposing  Causes. — Chorea  may  occur  at  any  age;  it 
is  most  commonly  seen  between  six  and  fifteen;  it  is  rare  under  three  and 
a  half  years  of  age.  It  occurs  from  two  to  three  times  more  frequently  in 
females  than  in  males.  It  is  uncommon  in  the  negro.  It  may  occur  at 
any  season  of  the  year,  but  is  much  more  prevalent  during  the  latter  part 
of  the  winter  and  spring.  The  prevalence  of  this  disease  between  the 
months  of  February  and  June  is  not  altogether  due  to  climatic  conditions ; 
acute  infections  and  the  nervous  strain  of  school  life  may  perhaps  be  im- 
portant factors  in  increasing  the  number  of  cases  during  this  season  of 
the  year.  A  family  history  of  neurotic  disease,  gout,  rheumatism,  migraine, 
or  tuberculosis  is  very  common.  Chronic  anemia  and  chronic  malnutri- 
tion are  among  the  most  important  predisposing  factors;  children  of  this 
type  have  irritable,  unstable,  nervous  systems,  which  make  them  very  sus- 
ceptible to  functional  nervous  diseases  of  all  kinds,  and  especially  to  chorea. 
Chronic  lymph-node  tuberculosis,  which  is  the  most  important  anemia 
producer  of  childliood,  is  an  important  etiological  factor  of  many  cases  of 
chorea.  Chronic  gastrointestinal  disturbances  and  chronic  malaria  may 
also  be  etiologically  related  to  chorea. 

Exciting  Causes. — Toxins  acting  on  the  central  nervous  system  are 
responsible  for  most  of  these  cases.  These  toxins  may  be  either  bacterial 
or  autogenetic,  or  they  may  be  either  systemic  or  intestinal.  In  the  great 
majority  of  instances  it  is  impossible  to  name  the  character  or  locate  the 
origin  of  these  toxins,  and,  on  the  other  hand,  it  is  altogether  probable  that 
there  is  a  group  of  so-called  idiopathic  choreas  associated  with  profound 
nutritional  and  functional  disturbances  of  the  brain,  in  which  there  may  be 
a  question  as  to  the  presence  of  any  toxic  factor. 

Eheumatism  is  the  most  important  cause  of  chorea;  it  is  present  in 
from  25  to  30  per  cent,  of  all  cases.  This  percentage  may  be  definitely 
ascribed  to  acute  rheumatic  fever,  whose  specific  cause  is  unknown.  If, 
however,  the  term  rheumatism  is  used  loosely  to  designate  the  various  forms 
of  arthritis  which  follow  such  acute  and  chronic  infections  as  tonsillitis, 
septicemia,  tuberculosis,  scarlatina,  influenza,  diphtheria,  typhoid  fever, 
measles,  gonorrhea,  and  syphilis,  then  a  much  larger  percentage  of  the 
cases  of  chorea  will  be  found  to  accompany,  or  follow,  this  syndrome.  All 
of  the  above-named  acute  infections,  especially  tonsillitis,  tuberculosis, 
and  scarlatina,  are  not  uncommonly  followed  by  chorea. 

Endocarditis  is  present  in  about  25  per  cent,  of  the  cases.  Cheadle 
and  many  other  writers  have  called  special  attention  to  the  relationship 
which  exists  between  tonsillitis,  arthritis,  endocarditis,  and  chorea.  All 
heart  murmurs  occurring  during  chorea  are  not  due  to  endocarditis.  In 
many  instances  there  may  be  a  weakening  or  irritability  of  the  cardiac 
muscles,  producing  a  very  distinct  cardiac  murmur,  which  disappears, 
leaving  the  heart  in  a  normal  condition,  when  the  attack  of  chorea  has 
subsided.  The  cardiac  murmurs  present  in  highly  neurotic,  anemic  chil- 
dren are  very  commonly  not  of  organic  origin.  The  common  association 
of  endocarditis  with  chorea  should  lead  one  to  suspect  organic  disease  of 


698  GENEEAL  NEEVOUS  DISEASES 

the  heart  in  all  cases  where  a  murmur  is  present,  until  it  can  ])e  definitely 
proven  that  the  heart  is  not  tliseased. 

Fright,  which  by  nearly  all  writers  is  classed  as  one  of  the  important 
exciting  causes  of  chorea,  is  responsible  for  the  onset  of  the  attack  in  a 
considerable  percentage  of  cases.  The  fright,  however,  is  made  potent  by 
the  presence  of  other  very  important  predisposing  factors,  such  as  mal- 
nutrition and  general  nervous  irritability.  Among  other  exciting  factors 
one  may  mention  intestinal  parasites,  gastrointestinal  diseases,  eye-strain, 
diseases  of  the  nose  and  pharynx,  phimosis,  masturbation,  delayed  menstru- 
ation, pregnancy  and  imitation. 

Duration. — The  average  duration  is  about  ten  weeks ;  mild  cases  get  well 
in  two  or  three  weeks,  and  severe  ones  may  continue  for  months.  Cases 
with  severe  cardiac  lesions,  or  grave  nutritional  disturbances,  may  continue 
for  six  or  more  months.  Those  that  continue  for  years  are  due  to  organic 
disease  of  the  nervous  system. 

Recurrence. — Children  who  have  had  chorea  should  be  kept  closely  un- 
der observation  for  a  number  of  years  to  prevent  a  recurrence.  Attacks 
may  recur  at  the  same  time  of  the  year  until  the  etiological  factors  which 
produced  the  first  attack  have  been  removed,  or  until  age  confers  immu- 
nity; recurrences  are  not  common  after  fifteen.  Second  and  third  attacks 
occur  in  about  one-third  of  all  cases.  Children  suffering  from  profound 
nutritional  disturbances  or  from  chronic  diseases  of  the  nose  and  throat,  or 
from  organic  disease  of  the  heart,  are  more  likely  to  have  subsequent  at- 
tacks. 

Prognosis. — This  is  nearly  always  good.  When  death  occurs  it  is  due 
to  cardiac  disease  or  to  the  organic  disease  of  which  the  chorea  is  a  symp- 
tom. 

Symptomatology. — Characteristic  Symptoms. — Before  the  character- 
istic symptoms  of  chorea  develop,  the  child,  as  a  rule,  is  anemic,  nervous 
and  irritable.  At  school  the  teacher  may  observe  his  inability  to  sit  still 
and  a  clumsiness  in  the  handling  of  objects.  The  dropping  of  pencils, 
books  and  other  things  brings  reproof  under  which  the  child's  restlessness 
increases.  Later,  twitchings  of  the  muscles  of  the  shoulder,  face,  or  hand 
suggest  the  nature  of  the  illness.  In  the  early  history  of  mild  attacks  the 
child  may  be  able  to  partly  control  these  irregular,  purposeless,  jerky 
movements,  but  the  muscular  spasm  in  these  cases  may  be  aggravated  by 
directing  it  to  perform  some  rather  delicate  movements,  such  as  threading 
a  needle,  or  lifting  a  pin  from  a  smooth  surface.  The  early  awkwardness 
of  choreic  children  may  sometimes  be  noted  by  their  tripping,  stumbling 
gait,  or  by  peculiar  muscular  contractions  which  momentarily  distort  the 
face.  Very  soon,  following  these  early  symptoms,  unmistakable  and  more 
or  less  general  choreic  movements  develop,  and  then  the  diagnosis  may  be 
made  at  a  glance. 

There  is  probably  no  more  clearly  defined,  or  more  characteristic,  symp- 
tom group  than  that  of  well-marked  chorea.  The  involuntary  inconstant, 
incoordinate,  jerky  muscular  contractions,  involving  the  whole  or  part  of 


CHOREA  699 

the  l)ody  and  aggravated  by  efforts  to  control  them,  present  an  unmistakable 
syndrome.  These  irregular  muscular  movements  vary  greatly  in  severity; 
mild,  as  a  rule,  in  the  beginning,  and  confined  perhaps  to  one  member  of 
the  body;  in  a  short  time  they  extend  to  the  whole  or  half  the  body  and 
increase'  in  severity,  until  at  the  end  of  the  second  week  they  have  reached 
their  maximum.  At  this  time  in  severe  cases  the  muscular  contractions 
are  almost  constant  and  the  whole  body  may  be  undergoing  bizarre  move- 
ments, which  twist  or  distort  it  to  such  an  extent  that  the  patient  may  be 
unable  to  maintain  an  upright  position.  The  limbs  are  jerked  and  twisted 
in  more  or  less  constant  movement,  and  every  voluntary  effort  increases 
these  incoordinate  muscular  contractions.  In  the  less  severe  cases  the 
child  may  be  able  to  go  about  as  usual,  and  have  limited  control  of  the 
spasmodic  muscular  movements,  so  that  he  is  able  to  pick  up  a  pin,  button 
his  clothes,  or  make  letters  with  a  pencil,  but  all  voluntary  movements  of 
this  kind  are  made  after  a  few  moments  of  deliberate  preparation,  and  then, 
the  act  is  carried  out  with  great  rapidity. 

Speech  may  not  be  disturbed,  but,  as  a  rule,  even  in  mild  cases  there  are 
marked  deliberation,  hesitancy,  and  some  irregularity.  In  more  severe 
cases  the  choreic  movements  involve  the  tongue  and  muscles  of  the  jaw, 
and  produce  an  irregularity  of  the  respiratory  rhythm.  In  these  cases 
the  articulation  is  imperfect  and  jerky;  the  patient  hesitates  and  then 
speaks  rapidly.  The  control,  however,  of  the  muscles  of  articulation  may 
be  lost  in  the  middle  of  a  word  or  a  sentence,  and  in  severe  cases  articula- 
tion may  be  impossible.  The  muscles  of  the  larynx  may  be  involved,  pro- 
ducing irregularity  in  the  tone,  pitch  and  volume  of  the  voice;  an  effort 
to  speak  may  produce  a  whisper,  a  barking  sound,  and  other  unusual 
noises.  The  muscles  of  deglutition  may  be  affected,  producing  difficulty 
in  swallowing. 

In  severe  cases  of  chorea  the  muscles  become  so  exhausted  by  constant 
movement  that  they  appear  to  be  paralyzed.  There  may  be  also  an  actual 
loss  of  muscular  power,  and,  in  rare  instances,  this  may  amount  to  par- 
alysis. During  sleep  the  choreic  movements  subside,  except  in  the  most 
severe  cases;  this  muscular  rest  gives  the  tired  muscles  an  opportunity 
to  recover  their  tone. 

Choreic  movements,  as  a  rule,  are  general.  In  about  one-quarter  of 
the  cases  they  are  confined  to  one  side  of  the  body;  these  cases  of  hemi- 
chorea  do  not  differ  materially  in  other  particulars  from  those  which  in- 
volve the  whole  body. 

Choreic  children  are  usually  quick-witted,  irritable,  emotional,  and 
suffer  from  headaches  and  general  nervous  exhaustion.  As  the  disease 
progresses  they  may  become  more  irritable,  disobedient  and  selfish.  In 
very  severe  cases  hallucinations,  delirium,  and  even  acute  mania  and  melan- 
cholia may  develop;  these  latter  symptoms  are  extremely  rare. 

Reflexes  are  so  variable  that  they  are  of  little  diagnostic  importance. 
They  are  commonly  normal,  sometimes  quickened,  or  they  may  be  dim- 
inished, and,  in  rare  instances,  absent. 


700  GENERAL  NERVOUS   DISEASES 

Well-marked  anemia  is  a  very  common  symptom  of  chorea. 

Urine. — There  is  nothing  specific  in  the  urine  findings;  albuminuria 
and  glycosuria  are  occasionally  noted ;  uric  acid,  as  a  rule,  occurs  in  excess. 
Herter  demonstrated  the  presence  of  hematoporphyrin  in  the  urine,  both 
of  chorea  and  rheumatism. 

Heart  Symptoms. — In  every  case  of  chorea  the  heart  should  be  watched 
throughout  for  evidence  of  "cardiac  disease,  A  rise  of  temperature  with- 
out apparent  cause  is  strongly  suggestive  of  cardiac  involvement.  If  a 
cardiac  murmur  develops,  the  case  is  to  be  treated  as  endocarditis.  Prac- 
tically all  of  the  diastolic  murmurs  are  organic;  systolic  murmurs  at  the 
base  near  the  sternum  are  commonly  hemic  and  due  to  anemia;  apical  sys- 
tolic murmurs  usually  mean  endocarditis,  but  they  may  be  due  to  myo- 
cardial insufficiency,  and  entirely  disappear  during  convalescence.  Osier 
has  called  attention  to  the  fact  that  many  murmurs  diagnosed  as  hemic  or 
functional  are  later  found  to  be  organic.  Pericarditis  may  also  complicate 
chorea. 

Treatment. — General  Treatment. — It  should  be  remembered  that 
chorea  is  generally  self-limited,  and  that  mild  cases  can,  for  the  most  part, 
be  satisfactorily  treated  with  little  medication. 

In  beginning  the  treatment  all  apparent  sources  of  reflex  irritation 
should  be  removed,  and,  above  all,  the  intestinal  canal  should  receive  most 
careful  consideration.  A  cathartic  should  be  given,  preferably  calomel, 
followed  by  castor  oil.  Intestinal  fermentation  should  be  corrected  by 
proper  food  and  medication.  The  diet  is  important  in  all  cases;  the  food 
should  be  selected  to  suit  the  individual  child's  digestive  capacity.  Milk 
is  an  ideal  diet,  unless  intestinal  disease  or  an  idiosyncrasy  forbids  its 
use.  Chicken  and  beef  in  small  quantities  may  be  allowed,  and  cooked 
fruits  and  easily  digested  vegetables  may  be  given.  Coffee,  tea,  strong  beef 
soups,  sweets,  pastries,  and  all  indigestible  food  are  contraindicated. 

Rest,  both  of  body  and  mind,  is  necessary.  In  mild  cases  it  may  be 
possible  to  get  on  fairly  well  without  putting  the  child  to  bed,  provided 
he  is  kept  moderately  quiet  and  not  allowed  to  engage  in  childish  sports 
with  other  children.  In  severe  cases  the  child  should  be  put  to  bed  and 
kept  there  until  the  paroxysm  commences  to  subside,  and,  thereafter,  until 
convalescence  is  established,  he  should  spend  the  greater  portion  of  the 
time  in  bed.  In  the  most  severe  cases  the  railing  about  the  bed  should  be 
high  and  well-padded  to  prevent  convulsive  movements  from  throwing  the 
child  out  of  bed,  or  from  injuring  him  by  knocks  against  hard  objects. 
The  bodily  rest,  which  is  so  important  in  the  treatment  of  uncomplicated 
chorea,  is  even  more  important  when  there  is  a  concurrent  endocarditis. 
Mental  rest  is  quite  as  important  as  bodily  rest.  Nervous  strain  and  men- 
tal work  should  be  reduced  to  a  minimum.  The  tactful  mother  and  nurse 
when  properly  directed  will  be  able  to  interest  the  child  without  tiring  or 
irritating  him. 

Medical  Treatment. — Arsenic  is  the  most  valuable  remedy  we  have 
in  the  treatment  of  the  attack.     In  some  cases  it  undoubtedly  exercises  a 


HABIT-SPASM    AND    OTHER    HABIT    NEUROSES        701 

controlling  influence  over  the  symptoms  and  shortens  the  duration  of  the 
disease.  In  giving  arsenic  one  should  commence  with  small  doses,  2 
or  3  minims  well  diluted  with  water,  three  times  a  day.  After  a  few 
days,  when  it  has  been  ascertained  that  the  arsenic  will  be  tolerated,  the 
dose  is  to  be  gradually  increased  until  the  patient  is  taking  10  or  12  minims 
three  times  a  day;  larger  doses,  as  a  rule,  are  unnecessary,  and  it  is  unwise 
to  steadily  increase  the  arsenic  until  the  characteristic  signs  of  arsenic 
poisoning  are  produced.  These  symptoms  are  headache,  irritable  stomach, 
diarrhea,  and  puffiness  of  the  face,  and  should  they  make  their  appear- 
ance at  any  time  during  the  administration  of  the  arsenic,  this  drug  should 
be  at  once  stopped  for  a  week  or  ten  days,  and  then,  if  continued  at  all, 
should  be  given  in  small  doses.  In  giving  arsenic  as  above  described  the 
maximum  dose  of  10  or  12  drops  should  be  continued  for  a  few  days  only, 
and  the  dose  should  then  be  gradually  diminished  until  the  patient  is 
taking  from  3  to  5  drops  three  times  a  day.  After  giving  the  arsenic  for 
two  weeks,  if  decided  improvement  in  the  symptoms  has  not  resulted,  it 
should  be  discontinued. 

Sodium  salicylate  (wintergreen),  aspirin,  and  salol  may  be  used  with 
advantage  in  rheumatic  cases.  Warm  baths  and  mild  laxatives,  such  as 
sodium  phosphate,  are  of  value.  In  eases  associated  with  profound 
anemia  and  malnutrition,  iron,  cod-liver  oil,  and  a  diet  of  meat,  eggs  and 
milk  are  indicated.  Quinin  is  of  value  only  in  those  cases  where  there  is 
a  malarial  intoxication. 

Sedative  medication  may  be  indicated  in  very  severe  cases.  Chloral 
hydrate,  veronal,  and  potassium  bromid  may  be  used  to  produce  sleep,  and, 
in  rare  instances,  hydrobromate  of  hyacin,  or  morphin  hypodermically,  or 
chloroform  by  inhalation  may  be  necessary  to  control  severe  muscular 
contractions. 

Following  an  attack  of  chorea,  when  the  patient  is  thoroughly  con- 
valescent, he  should  have  his  nose  and  throat  carefully  investigated.  Ton- 
sils and  adenoids  enlarged  by  disease  are  open  portals  through  which  in- 
fections capable  of  producing  chorea  may  enter  the  body;  they  should 
therefore  be  removed  to  prevent  acute  infections.  Rheumatic  cases  may 
require  a  change  of  climate  to  avoid  the  damp,  cold  months  of  the  winters 
in  our  middle  and  northern  States. 

In  the  treatment  of  those  cases  in  which  there  is  an  underlying  pro- 
found anemia  and  malnutrition,  the  syrup  of  the  iodid  of  iron,  cod-liver 
oil,  fresh  air,  good  food,  and  appropriate  liygienic  measures  should  be  con- 
tinued until  the  child  is  restored  to  health. 

HABIT-SPASM  AND  OTHER  HABIT  NEUROSES 

Habit-spasm,  or  tic,  is  a  pure  neurosis  characterized  by  sudden  and 
quick  contractions  which  assume  somewhat  the  character  of  convulsive 
movements.     In  the  beginning   these  movements  appear  to  be  voluntary. 


703  GENEEAL  NERVOUS   DISEASES 

but  by  repetition  they  become  habitual  and  involuntary.  They  occur  most 
frequently  in  the  muscles  of  the  face,  neck  and  shoulders. 

Etiology. — Tic  is  in  no  way  related  to  chorea.  The  clinical  pictures 
which  the  two  conditions  present,  and  the  etiological  factors  which  pro- 
duce them,  are  quite  different.  Heredity  is  the  most  important  predis- 
posing factor.  These  patients,  as  a  rule,  have  unstable  and  easily  ex- 
citable nervous  systems  inherited  from  neurotic  ancestors.  Tic  is  com- 
monly associated  with  other  neurotic  disorders.  Malnutrition  and  anemia 
are  frequently  present.  These  exciting  factors  may  be  brought  about  by 
bad  hygienic  surroundings,  improper  food,  chronic  intestinal  indigestion, 
chronic  intoxications,  systemic  and  intestinal,  and,  in  fact,  by  any  patho- 
logical condition  which  undermines  the  child's  general  health.  Tic  rarely 
occurs  before  the  third  year  of  life.  It  most  usually  has  its  onset  be- 
tween the  fifth  and  the  fourteenth  years.  The  development  of  the  re- 
productive organs  and  school  life  are  important  causative  factors.  School 
life  brings  to  bear  on  the  irritable  nervous  systems  of  neurotic  children 
the  etiological  factors  which  are  most  important  in  the  development  of 
habit-spasm.  The  mental  training,  confinement,  restraint,  enforced  quiet, 
unhygienic  surroundings,  anxiety  to  excel,  and  increased  eye-strain  which 
school  life  entails  may  all  be  factors  in  aggravating  the  neurotic  tenden- 
cies of  nervous  children,  and  more  or  less  directly  lead  to  habit-spasm. 

Imitation  and  reflex  irritation  from  ej'e-strain,  or  disease  of  the  ej^es, 
nose,  throat,  and  pharynx  are  among  the  common  exciting  causes  of  tic. 

Symptomatology. — The  child  is  nervous,  restless,  quick  of  movement, 
and,  as  a  rule,  bright  of  mind.  But  the  characteristic  symptom  is  re- 
curring spasmodic  movements  in  one  or  more  groups  of  muscles,  com- 
monly in  the  face,  neck  or  shoulders.  In  an  individual  case  the  same 
movements  are  usually  repeated.  There  may  be  rapid  winking  or  blink- 
ing of  the  eyes,  with  the  drawing  of  the  mouth  downward  and  to  the  side, 
distorting  the  face.  The  eyebrows  may  be  raised  or  lowered,  as  in  frown- 
ing. A  sudden  twisting  or  shaking  of  the  head  and  shrugging  of  the  shoul- 
ders are  very  characteristic  movements.  A  peculiar  inspiratory  sniff 
with  the  lifting  of  the  alae  of  the  nostrils  occurs  in  some  cases.  Hyper- 
esthesia of  the  skin  may  be  associated  with  this  condition.  Habit-spasm 
of  muscle  groups  in  arms  and  legs  may  also  occur,  but  is  not  common. 
The  spasmodic  movements  in  tic  may  recur  at  short  intervals,  especially 
when  the  patient  is  under  observation.  Attention  to  and  discussion  of 
these  symptoms  increases  the  frequency  and  violence  of  the  contractions. 
They  may  almost  or  quite  disappear  during  the  vacation  months  if  this 
time  is  spent  in  a  quiet  country  place,  and  they  may  reappear  when  the 
child  returns  to  school  in  the  autumn.  The  worst  cases  are  seen  in  the 
latter  part  of  the  winter  and  early  spring  months;  in  these  there  are  usu- 
ally a  well-marked  malnutrition  and  anemia,  and  hemic  and  accidental 
cardiac  murmurs  may  be  heard  over  the  base  of  the  heart. 

Frogpiosis. — Habit-spasm,  or  simple  tic,  may  continue  for  many  months 
and  even  years;  as  a  rule,  however,  the  prognosis  is  good,  provided  the 


HABIT-SPASM  AND  OTHER  HABIT  NEUROSES         703 

hereditary  taint  is  not  too  strong  and  the  child  can  he  placed  under  the 
most  favorable  conditions  for  recovery.  We  are  not  here  interested  in  the 
convulsive  and  psychical  tics  which  may  occur  in  older  children  and  in 
adults. 

Treatment. — The  treatment  of  simple  tic  should  begin  with  the  re- 
moval of  all  abnormal  conditions  which  may  possibly  be  a  source  of  reflex 
irritation;  eye-strain  and  nasal  and  pharyngeal  irritation  should  receive 
special  attention.  The  child  should  be  taken  out  of  school  and  have  such 
mental  training  as  is  thought  necessary  at  home.  It  should  be  protected 
from  all  forms  of  mental  excitement,  and  its  surroundings  should  be 
such  that  attention  would  never  be  called  to  the  spasm.  In  young  chil- 
dren the  attendants  should  deny,  if  necessary,  in  the  presence  of  the  child, 
the  very  existence  of  the  spasm.  In  older  children  rewards  are  sometimes 
efficacious.  Children  suffering  from  tic  should  not  be  permitted  to  play 
with  other  nervous  children,  since  the  disease  by  imitation  may  be  com- 
municated to  others. 

An  outdoor  life,  peaceful,  quiet  surroundings,  well-directed  exercise,  a 
carefully  selected  nutritious  diet,  and  medication  such  as  may  be  indicated 
to  relieve  the  particular  form  of  malnutrition,  indigestion  or  intoxication, 
which  may  be  the  basic  factor  in  an  individual  case,  are  in  every  instance 
part  of  the  general  treatment.  It  may  be  necessary  by  proper  medication, 
diet,  fresh  air,  and  general  hygienic  measures  to  treat  an  underlying  mi- 
grainous or  uric  acid  diathesis,  or  a  tuberculous  anemia. 

Drugs  are  of  little  value  in  the  treatment  of  this  condition,  but  the 
bromids  may  be  used  for  a  time  to  control  symptoms. 

Thumb-sucking  is  a  habit  neurosis  which  has  its  origin  in  the  animal  in- 
stinct of  self-preservation  which  causes  the  infant  to  suck  everything  that 
comes  in  contact  with  its  lips.  The  child  by  instinct  conveys  to  its  mouth 
everything  that  touches  its  hands,  and  when  nothing  happens  to  be  in  the 
hand  the  child  places  its  thumb,  fingers  or  some  other  portion  of  its  body 
in  its  mouth.  In  this  way  the  injurious  habit  of  almost  constant  sucking 
is  gradually  developed.  In  the  beginning  the  act  is  done  in  response  to 
normal  instincts,  but  after  a  time  the  sucking  habit  is  gradually  formed, 
and  then  the  infant,  during  the  greater  portion  of  its  waking  moments, 
indulges  this  habit  and  seems  to  get  comfort  and  satisfaction  from  the 
act.  When  this  habit  is  once  formed  the  infant  does  not,  as  in  the  begin- 
ning, suck  promiscuously  anything  that  happens  to  come  in  contact  with 
its  mouth,  but  confines  the  habit  to  some  particular  object,  such  as  a 
thumb,  finger,  toe,  the  tongue,  a  rubber  nipple,  a  piece  of  cloth,  or  some 

special  toy. 

The  habit  of  sucking  does  not  produce  any  notable  constitutional  dis- 
turbances and  does  not  apparently  influence  the  growth  and  development 
of  the  nervous  system,  and  the  infant  is  allowed  to  form  this  habit  be- 
cause the  mother  or  the  physician  does  not  believe  it  is  worth  while  to  try 
to  prevent  the  formation  of  a  habit  which  gives  the  child  a  pleasurable 
occupation  and  does  not  seriously  interfere  with  its  development.  The 
46 


704  GENERAL  NERVOUS   DISEASES 

sucking  habit,  however,  does  produce  certain  deformities  of  the  part 
sucked,  and  may  also  lead  to  irregularities  in  the  development  of  the 
mouth.  The  deformities  of  the  mouth,  thumbs  and  fingers  may,  in  ag- 
gravated instances,  be  so  pronounced  that  they  are  noticeable  when  the 
child  grows  up.  It  is  for  the  purpose  of  preventing  these  deformities  that 
the  sucking  habit  should  be  corrected. 

If  the  child  is  allowed  to  indulge  in  this  habit  for  months  or  years,  it 
may  be  necessary  to  use  some  mechanical  device  which  makes  it  impos- 
sible for  the  child  to  continue  it.  WTien  the  habit  has  been  indulged  in  for 
only  a  short  period  of  time,  it  may  be  possible  to  overcome  it  by  covering 
the  thumb,  fingers,  or  parts  sucked  with  bandages  or  mittens  carrying  so- 
lutions of  quinin  or  aloes.  These  bitter  solutions,  however,  are  of  little 
value  when  the  habit  is  well  formed.  The  mechanical  means  wliich  may 
be  used  may  vary  with  the  individual  child  and  with  the  part  of  the  body 
sucked.  Punishment,  as  a  rule,  does  not  favorably  influence  this  habit, 
but  rather  teaches  the  child  deception.  Older  children  may  l)e  influenced 
by  rewards  or  by  appealing  to  their  sense  of  shame.  The  sucking  habit  is 
always  more  difficult  of  treatment  in  nervous,  malnourished  children,  and, 
for  this  reason,  malnutrition  and  other  causes  of  nervousness  should  be 
carefully  treated  before  an  attempt  is  made  to  break  up  the  habit  of  suck- 
ing by  mechanical  restraint. 

PICA 

Pica,  or  dirt-eating,  is  a  habit  neurosis  which  manifests  itself  in  a 
curious  perversion  of  appetite.  The  infantile  type  of  this  disease,  in  which 
we  are  here  interested,  commonly  begins  before  the  second  year  of  life 
and  tends  to  spontaneous  recovery  before  the  fifth  year.  The  animal  in- 
stinct of  self-preservation  which  causes  the  infant  to  put  everything  it 
touches  into  its  mouth  is  the  most  important  factor  in  starting  this  neuro- 
sis. It  occurs  most  commonly  in  neurotic,  malnourished  children,  and  is 
very  frequently  associated  with  gastrointestinal  disorders.  In  older  chil- 
dren imitation  is  an  important  factor.  Functional  disturbances  of  the 
stomach,  which  produce  a  burning,  gnawing  sensation  that  is  relieved  by 
the  eating  of  dirt,  chalk.  Fuller's  earth,  and  other  absorbents,  may  be  im- 
portant and  troublesome  factors  in  developing  and  continuing  this  habit 
neurosis.  Whatever  may  be  the  predisposing  or  exciting  causes  which  have 
been  active  in  starting  the  practice  of  dirt-eating,  the  habit  which  is  thus 
formed  becomes  the  important  etiological  factor  which  impels  the  patient 
to  continue  to  satisfy  this  perverted  appetite. 

Symptomatology. — The  strange  perversion  of  appetite  in  these  children 
causes  them  to  forego  wholesome,  appetizing  food  for  such  innutritions  and 
indigestible  things  ds  dirt,  plaster,  sand,  gravel,  chalk.  Fuller's  earth,  clay, 
ashes,  cinders,  coal,  soapstone,  slate-pencils,  paper,  rags,  hair,  and  some- 
times such  disgusting  materials  as  their  own  excrement.  In  some  instances 
children  will  refuse  to  take  all  foods  except  sweets,  such  as  candy  and 


HYSTERIA  705 

sugar ;  this  sugar-eating  habit  may  lead  to  dirt-eating,  and  the  development 
of  troublesome  and  disgusting  types  of  pica.  Many  patients  who  practice 
the  habit  of  dirt-eating  may  take  for  a  considerable  time  a  sufficient  quan- 
tity of  nutritious  food;  as  the  habit  develops,  however,  the  tendency  is  to 
gradually  increase  the  quantity  of  dirt  taken  and  diminish  the  quantity 
of  food.  Such  patients  may  become  anemic,  malnourished  and  emaciated, 
and  may  develop  intestinal  disorders. 

Prognosis. — This  is  good.  The  great  majority  of  these  cases  recover 
under  proper  treatment  before  the  child  is  three  years  of  age.  A  few  of 
them  continue  into  the  third  or  fourth  year,  and  neglected  cases  may  de- 
velop into  the  more  severe  forms  of  pica  seen  in  late  childhood  and  adult 
life. 

Treatment. — The  first  step  in  the  treatment  is  to  place  these  patients 
under  such  supervision  that  it  is  absolutely  impossible  for  them  to  con- 
tinue the  habit;  if  the  habit  is  forcibly  broken  it  gradually  loses  its  hold 
upon  the  nervous  system,  and  this  measure  is,  therefore,  a  curative  one. 
The  next  important  step  is  to  prescribe  a  proper  dietary,  suitable  to  the 
age  and  digestive  capacity  of  the  patient.  The  food  problem  is  especially 
important,  since  the  dietetic  treatment  usually  comprehends  the  removal  of 
some  gastrointestinal  irritation.  In  cases  where  food  is  absolutely  re- 
fused (anorexia  nervosa)  it  may  be  necessary  to  feed  by  gavage.  Alkalies 
such  as  bicarbonate  of  soda  or  benzoate  of  soda  exert  a  favorable  influence 
in  these  cases;  they  may  perhaps  act  by  neutralizing  fermentation  and 
other  acids  in  the  stomach,  and  thus  correct  one  cause  of  the  perverted 
appetite. 

HYSTERIA 

Definition. — Hysteria  is  a  psychoneurosis  due  to  functional  disturb- 
ances of  the  cortical  centers.  It  is  characterized  by  defective  will  power, 
emotional  excitability,  and  the  control  of  the  body  and  mind  by  perverted 
notions  and  fixed  ideas,  which  are  not  uncommonly  produced  by  sugges- 
tion. 

Etiology. —Hysteria  is  a  real,  not  a  simulated,  disease.  Its  most  im- 
portant etiological  factor  in  the  child  is  feeble  inhibition;  this  lack  of 
control  results  in  apparently  insignificant  causes  producing  exaggerated 
motor  and  psychic  phenomena.  Hysteria  is  more  common  in  the  adult 
than  in  the  child,  but  is  not  infrequently  seen  in  late  infancy  and  early 
childhood,  and  is  very  common  between  the  ages  of  ten  and  fifteen.  Hered- 
ity is  a  Very  powerful  predisposing  factor;  a  strong  neurotic  taint  is 
commonly  present.  There  may  be  a  family  history  of  hysteria,  chronic  al- 
coholism, epilepsy,  insanity,  chorea,  or  general  nervous  irritability.  The 
wor'^t  cases  occur  in  families  that  are  mentally  degenerate.  There  is  a 
marked  preponderance  of  females,  but  this  is  not  so  great  in  children  as 

in  adults.  j.  i_    i.    •     •      i,-i 

Malnutrition  is  one  of  the  important  direct  causes  of  hysteria  in  chil- 


706  GENERAL  NERVOUS   DISEASES 

dren.  The  term  malnutrition  is  here  used  very  broadly,  not  only  to  in- 
clude innutrition  and  partial  starvation  of  nerve  cells,  which  result  from 
lack  of  sufficient  food  and  bad  hygienic  surroundings,  but  it  also  compre- 
hends the  condition  of  nerve  cells  which  results  when  they  are  fed  with 
blood  containing  auto,  intestinal  or  bacterial  toxins.  Not  only  poor  blood, 
but  bad  or  poisoned  blood,  is  important  in  the  etiology  of  hysteria  in  in- 
fancy and  childhood. 

Environment  is  a  very  important  exciting  cause.  Hysteria  is  more 
common  in  the  city  than  in  the  country,  not  only  because  of  impure  air 
and  bad  hygiene,  but  also  because  of  the  noise,  the  rush,  and  the  strain  of 
life  in  a  large  city,  where  the  child  is  subjected  to  constant  excitement  and 
increased  mental  activity.  The  strain  of  school  life  and  school  examina- 
tions, the  lack  of  home  discipline,  which  allows  self-indulgence  and  free 
play  to  the  emotions,  and  the  close  association  of  members  of  a  neurotic 
family  may  all  be  factors  in  the  development  of  this  disease.  Great  grief, 
emotional  excitement,  great  physical  or  mental  strain,  nervous  shock,  and 
sudden  fright  may  develop  hysteria  in  those  predisposed  to  this  disease  by 
malnutrition  or  heredity.  Severe  reflex  excitation,  such  as  may  come 
from  eye-strain,  intestinal  disorders  and  phimosis,  are  important  factors. 
Diseases  of  the  genital  organs  may  produce  hysteria  in  infants  and  young 
children.  Suggestion  is  one  of  the  most  potent  factors  in  developing 
symptom  groups  in  hysterical  patients.  Syndromes  may  be  suggested  by 
the  questions  of  the  examining  physician  or  by  the  story  of  another  pa- 
tient's s}Tnptoms  and  sufferings. 

Symptomatology. — Extreme  selfishness  and  dependence  are  common 
manifestations  of  hysteria.  The  defect  in  will  power  makes  the  patient 
dependent  upon  those  around  her.  She  is  often  controlled  by  fixed  ideas 
with  reference  to  her  inability  to  think  or  act  for  herself.  One  of  the 
most  peculiar  and  characteristic  examples  of  the  control  which  fixed  ideas 
have  over  hysterical  patients  is  shown  in  the  symptom  group  known  as 
astasia-abasia.  This  is  one  of  the  most  common  of  hysterical  manifesta- 
tions in  the  child,  and,  whatever  may  have  been  its  origin,  it  is  continued 
by  reason  of  the  fact  that  the  patient  has  a  fixed  idea  in  her  mind  that 
she  can  neither  Stand  nor  walk.  She  may  have  control  of  her  legs  when 
lying  down,  moving  them  at  will  in  any  direction,  but  the  minute  she  is 
placed  upon  her  feet  her  legs  give  way,  or  they  stiffen  and  she  loses  her 
equilibrium,  or  she  may  stand  upon  her  feet  and  not  be  able  to  walk, 
making  incoordinate  movements  of  the  legs  when  she  attempts  to  do  so. 

Paralysis,  which  is  a  common  manifestation  of  hysteria  in  the  adult, 
is  comparatively  rare  and  of  a  milder  type  in  young  children.  It  may  be 
flaccid  and  associated  with  diminished  reflexes,  but  it  is  commonly  spas- 
tic, associated  with  contractures  and  exaggeration  of  deep  reflexes.  Anes- 
thesia, which  is  so  common  in  the  adult,  and  often  associated  with  motor 
paralysis,  is  comparatively  rare  in  the  child.  The  paralysis  and  anes- 
thesia of  the  hysteria  of  childhood  do  not  differ  from  these  symptoms  as 
they  occur  in  the  adult,  except  that  they  are  less  frequent  and  less  intense. 


HYSTEKIA  707 

Painful  and  contractured  joints  occur  not  infrequently,  even  in  very 
young  children.  These  hysterical  manifestations  may  be  mistaken  for  tu- 
berculosis or  other  organic  disease.  Hysterical  aphonia  occurs  in  children. 
This  symptom  is  very  commonly  associated  v^'ith  globus  hystericus,  and  a 
persistent  dry,  hysterical  cough.  Hysterical  eclampsia  is  rare  in  young 
children,  but  may  occur  in  older  children,  and  presents  the  same  charac- 
teristics as  it  does  in  the  adult. 

In  the  emotional  forms  of  hysteria  fits  of  crying  and  laughing  may 
follow  each  other  without  apparent  cause.  These  patients  are  moody,  ir- 
ritable, and  are  easily  thrown  into  states  of  great  nervous  excitability.  In 
extreme  cases  catalepsy,  lethargy,  trance,  ecstasy  and  even  acute  mania 
may  occur ;  these  latter  symptoms,  however,  are  very  rare  in  the  child. 

Anorexia  nervosa  is  a  classical  symptom  group  which  is  very  common 
even  in  young  children,  and  it  may  occur  in  infancy.  In  this  condition 
the  patient  may  go  for  weeks  without  being  seen  to  retain  any  food;  the 
sight  of  food  may  produce  nausea,  and  all  food  taken  may  be  vomited, 
sometimes  with  a  conscious  effort.  The  severity  of  this  symptom  group 
may  vary  greatly;  in  young  infants  it  may  take  the  form  of  lack  of  ap- 
petite, so  that  all  food  is  refused.  In  these  cases  it  may  be  necessary  to 
resort  to  gavage  to  prevent  loss  of  weight  and  serious  malnutrition. 

The  urine  during  hysterical  attacks  is  light  colored,  of  low  specific 
gravity,  and  is  commonly  passed  in  large  quantities.  Anuresis  may  also 
occur. 

Treatment.— In  beginning  the  treatment  of  hysteria  it  is  important 
that  all  causes  of  reflex  irritation  to  the  nervous  system  should  be  removed. 
Eye-strain,  diseases  of  the  nose,  throat,  reproductive  and  genitourinary 
organs  should  receive  appropriate  treatment. 

The  next  step  comprehends  the  removal  of  the  underlying  causes  of 
the  chronic  anemias  and  malnutritions  so  commonly  found  in  hysterical 
patients.  In  order  to  do  this  it  is  not  only  necessary  to  prescribe  medi- 
cines, such  as  iron,  cod-liver  oil,  arsenic,  quinin,  or  some  tonic  that  will 
stimulate  the  appetite  and  improve  digestion,  but  it  is  of  even  greater  im- 
portance that  the  diet  and  hygienic  surroundings  should  be  carefully 
adapted  to  the  needs  of  the  individual  case.  Alcohol,  tea,  coffee,  sweets, 
salads,  pastries,  and  rich  and  highly  seasoned  dishes  should  be  avoided, 
and  a  diet  prescribed  which  is  simple,  wholesome,  nutritious  and  suitable 
•  to  the  digestive  capacity  of  the  patient  and  the  malnutritions  from  which 
she  suffers.  The  hysterical  patient  should  live  as  much  as  possible  out  of 
doors,  away  from  the  whirl,  noise  and  excitement  of  a  city,  and  moderate 
exercise  and  congenial  surroundings  should  be  insisted  upon. 

Kemoval  from  the  nervous  atmosphere  of  a  neurotic  household,  stop- 
ping of  all  mental  stimulation,  and  avoiding  nervous  excitement  are  im- 
portant factors  in  the  cure.  The  hysterical  patient  should,  if  possible,  be 
placed  under  the  care  of  a  nurse  whom  she  loves  and  in  whom  she  has  con- 
fidence This  attendant  should  be  of  good  physique,  of  sober  mind,  and 
full  of  tact,  and  she  should  have  sufficient  intelligence  to  study  the  pe- 


708  GEXEEAL  XERVOUS  DISEASES 

culiarities  of  her  patient's  mental  condition  so  that  she  may  tactfully  avoid 
touching  upon  topics  which  by  suggestion  may  influence  her  patient  un- 
favorably; she  should  also  be  able  to  utilize  the  fads  and  idiosyncrasies  of 
her  patient  in  such  a  way  as  to  prevent  her  from  dwelling  upon  her 
troubles.  The  successful  treatment  will  depend  largely  upon  the  ability  of 
the  physician  to  so  control  the  surroundings  of  his  patient  that  she  will  be 
constantly  influenced  by  wholesome  suggestions  — suggestions  that  she  is 
improving  from  time  to  time,  and  that  her  early  recovery  is  assured.  The 
influence  of  change  is  so  important  that  it  is  necessary  that  radical 
changes  should  be  made  in  the  surroundings  from  time  to  time.  In  older 
children  a  modified  Weir  Mitchell  rest-cure  is  often  of  great  advantage. 
The  confinement  to  bed,  massage,  forced  feeding,  isolation,  and  striking 
change  of  surroundings,  which  this  treatment  comprehends,  act  not  only 
by  suggestion,  but  the  treatment  itself  exercises  a  curative  influence.  Hy- 
drotherapy in  some  form  is  applicable  to  the  treatment  of  nearly  every  case 
of  hysteria;  the  cold  tub  bath,  or  cold  douche  to  the  spine,  may  be  used 
in  older  children  to  control  severe  paroxysms.  In  the  great  majority  of 
cases  a  warm  bath  followed  by  general  massage  and  an  alcohol  rub  is  of 
great  advantage.  Electricity  is  a  therapeutic  agent,  which  acts  largely 
by  suggestion;  in  the  treatment  of  aphonia  and  paralyses  of  various  kinds 
it  is  especially  valuable.  Blistering  the  skin  over  tender  areas  and  cau- 
terizing the  sensitive  spine  may  be  of  benefit  in  some  cases. 

Sedatives,  such  as  the  bromids,  valerian  and  asafetida,  may  be  used 
for  the  relief  of  nervous  symptoms,  but  they  should  not  be  continued  for 
any  great  length  of  time. 

HEADACHES 

Etiology. — Headaches  are  uncommon  in  children  under  five  years  of 
age,  but  when  they  do  occur  they  are  much  more  important  in  their  patho- 
logical significance  than  when  they  occur  later.  After  five  years  of  age 
headaches  are  more  frequent,  and  become  common  between  the  ages  of 
eight  and  fourteen,  but  even  during  this  period  they  are  nothing  like  so 
common  as  they  are  between  the  ages  of  twenty  and  forty. 

Heredity  is  an  important  predisposing  factor;  this  is  especially  true 
of  migrainous,  neurasthenic,  and  neuralgic  headaches.  These  cases  usually 
have  a  family  history  of  gout,  migraine,  neurasthenia,  hysteria,  or  general 
nervous  instability.  Feebleness  of  constitution  due  to  chronic  diseases  in 
the  parent  may  be  inherited  by  the  child  and  predispose  it  to  reflex,  toxic, 
anemic  and  other  varieties  of  headache. 

Anemic  Headache. — Malnourished,  anemic,  neurotic  children  may 
have  headaches  from  very  slight  exciting  causes,  and  the  pain  is  common- 
ly frontal,  or  vertical.  Any  chronic  disease  which  produces  malnutrition 
and  anemia  results  in  such  instability  and  irritability  of  the  vasomotor 
nerve  centers  that  headaches  may  be  produced  by  nervous  excitement, 
nervous  and  physical  fatigue,  nervous  shock,  fear,  anger,  mental  overwork. 


HEADACHES  709 

the  strain  ancl  confinement  incident  to  school  life,  and  by  all  kinds  of  toxic 
and  reflex  factors  capable  of  acting  upon  the  nervous  system. 

Eeflex  headaches  are  very  common  in  childhood,  especially  between 
the  ages  of  six  and  fourteen.  They  may  be  due  to  eye-strain,  adenoid 
growths,  undigested  food,  and  other  reflex  causes.  Ocular  defects  are  very 
common  in  children  of  school  age,  and  are  responsible  for  a  large  percen- 
tage of  the  chronic  headaches  from  which  school  children  suffer.  These 
headaches  come  on  after  using  the  eyes  and  grow  worse  toward  the  close 
of  the  school  day ;  they  are  usually  frontal  or  occipital  and  associated  with 
general  nervous  irritability. 

Toxic  headaches  of  gastrointestinal  origin  are  common  in  childhood 
and  may  be  associated  with  nausea,  vomiting,  flatulency,  diarrhea,  or 
constipation.  The  diagnosis  of  headaches  of  this  character  may  be  con- 
firmed by  the  relief  which  follows  cathartic  medication  and  careful  dietetic 
treatment.  In  children  over  six  years  of  age  they  may  be  more  or  less 
chronic,  persisting  for  weeks,  and  the  intestinal  toxemia  during  this  time 
may  be  overlooked.  In  this  type  the  presence  of  indican  and  indolacetic 
acid  in  excess  in  the  urine  may  call  attention  to  their  intestinal  origin. 

Toxic  headaches  are  also  produced  by  systemic  bacterial  poisons  acting 
on  the  nerve  centers.  This  type  occurs  in  all  the  acute  infectious  diseases 
and  is  especially  severe  in  influenza.  Periodic  headaches,  neuralgic  in 
character,  are  very  commonly  due  to  influenza  or  malaria;  the  supra-  and 
infraorbital  nerves  are  frequently  involved  and  remain  sensitive  to  touch 
in  the  interval  between  the  attacks  of  pain.  In  older  children  infections 
involving  the  antrum  of  Highmore,  frontal  sinus  and  other  bony  cavities 
of  the  face  may  produce  a  persistent,  periodic  pain  in  the  facial  nerves, 
which  may  be  mistaken  for  malarial  or  influenzal  neuralgia. 

Autotoxins  such  as  occur  in  uremia  may  produce  severe  toxic  head- 
aches. Uremic  headaches,  however,  are  much  less  severe  in  the  child  than 
they  are  in  the  adult.  They  are  commonly  occipital  and  are  associated 
with  vertigo,  nausea,  vomiting  and  the  urine  findings  of  acute  Bright's 
disease.  Migraine,  the  most  common  form  of  headache  produced  by  auto- 
toxins, is  elsewhere  described. 

During  infancy  and  early  childhood  disease  of  the  internal  ear  is  the 
most  common  form  of  pain  in  the  head. 

Organic  headache  may  be  due  to  meningeal  inflammation,  tumors  of 
the  brain,  cerebral  abscess,  and  injuries  to  the  brain  and  skull.  Head- 
aches of  this  character  are  severe,  persistent,  localized,  and  accompanied 
by  other  signs  of  organic  disease  of  the  brain  or  its  membranes. 

Treatment.— The  successful  treatment  of  headaches  in  childhood  must 
be  based  upon  a  careful  differential  diagnosis  of  the  various  etiological 
factors  and  their  relative  importance.  A  search  should  first  be  made  for 
reflex  factors,  giving  special  attention  to  eye-strain.  If  such  causes  be 
found,  they  should  be  removed  by  appropriate  treatment.  Attention  should 
next  be  directed  to  the  gastrointestinal  canal.  It  is  good  practice  to  begin 
the  treatment  of  all  kinds  of  headaches  with  some  form  of  cathartic 


710  GENERAL  NERVOUS   DISEASES 

medication,  such  as  calomel,  followed  by  castor  oil.  This  will  clear  the 
intestinal  canal  and  assist  materially  in  determining  the  importance  of  the 
role  which  gastrointestinal  factors  play  in  producing  the  headache.  If  the 
result  of  this  treatment,  the  character  of  the  headache,  and  the  nature  of 
the  gastrointestinal  discharges  justify  the  diagnosis  of  toxic  headache 
of  intestinal  origin,  then  the  further  treatment  will  consist  in  such  diet 
and  medication  as  will  remove  the  causative  condition.  If,  however,  the 
headache  is  produced  by  some  acute  bacterial  infection,  such  as  influenza, 
it  may  be  relieved  by  cathartic  medication,  the  application  of  cold  to  the 
head,  and  the  specific  treatment  of  the  infection  of  which  it  is  a  symptom. 
In  these  cases  one  is  justified  in  using  sedative  medication  to  relieve  the 
pain.  For  this  purpose  the  bromids  of  sodium  and  potash,  citrate  of 
caffein,  phenacetin  and  antipyrin  may  be  given  in  doses  suited  to  the  age 
of  the  child.  The  coal-tar  products,  however,  are  to  be  recommended  only 
in  the  treatment  of  acute  conditions,  and  should  be  continued  only  for  a 
short  time;  in  chronic  or  recurrent  headaches  their  continued  use  may 
do  harm. 

When  the  exciting  cause  of  the  headache  is  some  emotional  or  nervous 
excitement  brought  on  by  fear,  anger,  or  nervous  shock,  or  when  the  head- 
ache is  associated  with  extreme  nervous  irritability,  or  other  hysterical  or 
neurasthenic  symptoms,  an  ice-bag  to  the  head  and  good-sized  doses  of 
bromid  act  kindly  in  its  relief. 

Periodic  headaches  may  be  relieved  by  good-sized  doses  of  quinin  given 
in  the  interval  between  the  attacks  of  pain,  or  the  following  combination 
of  quinin,  arsenic  and  iron  may  be  used.  It  is  of  special  value  not  only 
in  periodic,  but  also  anemic,  headaches: 

IJ     Quinina^    sulph 2  gg 

Ferri   reducti    5  gg 

Acidi  arseniosi g-^  gg 

M.    Make  capsules;  number  20. 

S.     One  after  eating  for  a  child  eight  to  ten  years  of  age. 

It  should  be  remembered  that  even  after  the  headache  has  been  re- 
moved by  any  of  the  above-named  measures  there  may  yet  remain  to  be 
treated  the  constitutional  causes  of  the  general  nervous  irritability  which 
was  the  important  predisposing  cause  of  the  headache.  This  treatment 
comprehends  not  only  fresh  air,  proper  exercise,  suitable  food  and  well- 
directed  medication,  but  also  the  intelligent  direction  of  the  whole  life 
of  the  child,  so  that  he  may  be  properly  nourished,  his  constitutional  and 
local  diseases  eradicated,  and  his  nervous  system  so  protected  that  it  may 
recover  its  normal  tone  and  powers  of  resistance. 

ASTHMA 

Asthma  is  a  neurosis  characterized  by  recurrent  attacks  of  spasmodic 
dyspnea,  or  sibilant  bronchitis,  usually  associated  with,  or  followed  by,  a 
discharge  of  mucus  from  the  bronchial  tubes. 


ASTHMA  711 

Etiology. — The  underlying  causes  of  asthma  are  not  definitely  known, 
but  it  is  a  well-established  fact  that  in  this  condition  there  is  a  definite 
specific  underlying  predisposition  which  makes  it  possible  for  a  great 
variety  of  exciting  causes  to  produce  an  asthmatic  attack.  The  specificity 
of  the  underlying  predisposing  cause  is  demonstrated  by  the  fact  that  the 
same  exciting  cause  is  nearly  always  present  in  an  individual  case,  and 
that  the  many  exciting  factors  which  precipitate  attacks  of  asthma  in  cer- 
tain individuals  may  in  others  be  altogether  impotent  in  producing  an 
attack. 

The  bronchostenosis  which  occurs  in  all  cases  of  asthma  is  believed 
to  be  due,  in  some  cases,  to  a  vasomotor  disturbance  producing  a  swelling 
of  the  mucous  membranes  or  of  the  submucous  tissues  of  the  bronchioli, 
but  in  the  great  majority  of  cases  it  is  due  to  a  tonic  contraction  of  the 
muscle  fibers  of  the  smallest  bronchial  tubes. 

Asthma  is  much  more  common  in  adult  life,  but  it  may  occur  in  in- 
fancy and  early  childhood;  sibilant  bronchitis  is  relatively  more  common 
in  childhood.  Typical  attacks  of  spasmodic  asthma  become  more  common 
after  the  sixth  year  of  life,  and  increase  in  frequency  between  this  period 
and  adolescence.  Heredity  is  an  important  factor;  there  is  nearly  always 
a  family  history  of  neurotic  disease  or  gout.  Autotoxins  of  the  gouty  or 
lithemie  diathesis  may  precipitate  attacks  of  asthma.  Comby  classes  among 
the  respiratory  manifestations  of  lithemia  in  childhood  spasmodic  coryza, 
sibilant  bronchitis,  and  asthmatic  attacks  (see  Recurrent  Coryza).  Intes- 
tinal toxemia  is  an  important  exciting  cause  in  children.  Asthmatic  at- 
tacks may  be  precipitated  by  constipation,  overloading  the  stomach,  in- 
testinal indigestion,  and  gastrointestinal  disturbances  of  various  kinds, 
or  they  may  precede  or  follow  urticaria  of  the  skin.  Diseases  of  the  res- 
piratory tract,  such  as  catarrh  of  the  nasopharynx,  hypertrophied  turbi- 
nated bones,  enlarged  tonsils,  adenoids,  bronchitis,  whooping-cough,  in- 
fluenza, and  measles,  may  be  exciting  causes. 

In  especially  susceptible  individuals  the  pollen  of  certain  grasses  and  of 
rag-weed,  emanations  from  animals,  such  as  the  dog,  horse,  cat,  or  guinea- 
pig,  the  aroma  of  certain  medicines,  and  the  odor  of  certain  flowers  may 
be  specific  exciting  causes.  Among  other  exciting  factors  may  be  men- 
tioned dust,  irritating  vapors,  fright,  and  atmospheric  and  climatic  con- 
ditions. 

Symptomatology.— Asthmatic  attacks  resembling  the  adult  type,  while 
comparatively  rare  in  the  infant,  are  not  infrequent  in  older  children. 
They  may  recur  at  irregular  intervals,  weeks  or  months  intervening.  The 
severe  dyspnea  which  characterizes  these  attacks  may  recur  nightly  for  a 
time,  or  in  other  instances  may  continue  with  marked  severity  for  twenty- 
four' or  thirtv-six  hours,  and^hen  gradually  subside  into  convalescence. 
Typical  attacks  of  asthma,  as  a  rule,  begin  suddenly  in  the  night  with  a 
wheezing  respiration,  which  soon  becomes  a  marked  dyspnea.  The  child 
sits  up  in  bed,  fixing  his  shoulders  or  arms  so  as  to  bring  all  the  acces- 
sory muscles  of  inspiration  into  play  in  the  attempt  to  force  air  through 


712  GENERAL  NERVOUS   DISEASES 

the  contracted  bronchi  into  the  already  distended  air  vesicles.  Emphysema 
develops  and  gives  a  barrel-shaped  appearance  to  the  chest  in  the  later 
stages  of  the  attack.  Expiration  is  prolonged  and  accompanied  by  sono- 
rous wheezing  rales;  the  vesicular  murmur  may  be  inaudible.  After  a 
number  of  hours  the  dyspnea  gradually  subsides,  and  is,  as  a  rule,  followed 
by  a  cough  with  wheezing  large  moist  rales,  and  more  or  less  mucous  ex- 
pectoration. These  symptoms  may  continue  for  a  few  hours  or  for  days 
and  subside  into  convalescence. 

In  infants  and  young  children  afebrile  sibilant  bronchitis  with  slight 
dyspnea  is.  much  more  common  than  the  asthmatic  paroxysm  above  de- 
scribed. The  dyspnea  in  this  condition  may  not  be  very  great,  but  the 
number  of  respirations  is  markedly  increased,  and  sibilant,  wheezy  bron- 
chial sounds  occur,  which  may  persist  for  five  or  six  weeks.  During  this 
time  these  patients  have  no  pain,  suffer  comparatively  little  discomfort, 
go  about  the  house  and  amuse  themselves  without  complaining  of  feeling 
ill. 

La  Fetra  calls  special  attention  to  the  eosinophilia  which  occurs  in 
asthma.  He  says:  "The  leukocytes  are  iTSually,  but  not  always,  increased 
as  in  bronchitis,  but  a  differential  count  of  the  white  cells  shows,  what 
does  not  occur  in  bronchitis,  a  constant  and  usually  marked  increase  in  the 
number  of  polymorphonuclear  eosinophiles  (16  to  18  per  cent.)." 

Prognosis. — Patients  rarely  die  from  asthma,  and  the  prognosis,  so  far 
as  ultimate  recovery  is  concerned,  is  also  fairly  good,  provided  they  are  so 
situated  that  they  can  take  advantage  of  the  means  offered  for  its  cure. 
Chronic  cases,  which  have  gone  on  to  the  development  of  chronic  emphy- 
sema, do  not  yield  readily  to  any  form  of  treatment. 

Treatment. — Treatment  of  the  Attack. — Fresh  air  and  the  inliala- 
tion  of  the  fumes  of  stramonium  leaves  and  niter  paper  may  relieve  the 
paroxysm;  chloroform  by  inhalation  will  temporarily  arrest  the  attack. 
In  older  children  1/10  of  a  grain  of  morphin  given  hypodermically  may  be 
used  to  terminate  the  paroxysm.  Atropin,  1/1,000  of  a  grain,  with  nitro- 
glycerin, 1/300  of  a  grain,  given  hypodermically,  has  a  favorable  influence 
in  controlling  the  paroxysm ;  if  necessary  this  dose  may  be  repeated  in  two 
or  three  hours.  An  emetic  will  sometimes  cut  short  a  paroxysm  of  asthma, 
even  when  the  gastric  contents  have  little  to  do  with  exciting  the  attack ; 
syrup  of  ipecac  may  be  used  for  this  purpose.  Tincture  of  belladonna,  or 
atropin,  combined  with  bromid  of  potash,  chloral,  or  antipyrin,  in  doses 
suited  to  the  age  of  the  child,  is  a  valuable  remedy  for  modifying,  short- 
ening or  preventing  an  attack. 

Asthmatic  attacks  due  to  swelling  of  the  bronchial  mucous  membrane 
may  be  cut  short  by  local  applications  to  the  respiratory  passages  of  a 
solution  of  cocain  and  adrenalin  chlorid.  The  1  to  1,000  solution  of 
adrenalin  chlorid  may  also  be  used  hypodermically  in  1  to  3-minim  doses; 
this  remedy  at  times  acts  specifically  in  controlling  attacks  of  asthma. 

The  Interval  Treatment. — Adenoids,  large  tonsils,  nasal  hypertro- 
phies, and  all  diseases  of  the  nose  and  throat  should  receive  appropriate 


ASTHMA  713 

treatment.  Bronchitis,  whooping-cough,  measles,  influenza,  and  all  dis- 
eases which  produce  catarrli  of  the  bronchial  mucous  membranes  should 
be  studiously  avoided,  or,  if  present,  should  be  carefully  treated  until  all 
bronchial  irritation  has  disappeared. 

If  the  patient  has  a  well-marked  lithemic  history,  the  interval  treat- 
ment should  1)6  similar  to  that  recommended  in  the  chapter  on  Migraine. 
If  no  such  history  exists,  or  if  the  patient  fail  to  respond  to  this  treat- 
ment, iodid  of  potassium  or  syrup  of  hydriodic  acid  should  be  given  over 
a  long  period  of  time.  In  many  cases  iodin  medication  is  very  valuable  in 
helping  to  bring  about  a  cure,  and  should,  therefore,  be  given  a  trial  in 
every  case  in  which  some  other  special  form  of  tonic  medication  is  not 
especially  indicated.  Cod-liver  oil,  iron,  arsenic,  and  tincture  of  nux 
vomica  are  of  value  in  many  cases,  and  quinin  is  indicated  in  such  as 
have  previously  suffered  from  malaria.  All  medicines  which  diminish  the 
appetite,  or  produce  gastrointestinal  disturbances,  are  to  be  avoided. 

Asthmatic  attacks  associated  with  urticaria  of  the  skin  should  be 
treated  as  outlined  under  Urticaria. 

Change  of  climate,  or  change  of  locality,  is  the  most  important  factor 
in  the  relief  and  cure  of  asthma.  But  in  this  respect  it  is  difficult  to  lay 
down  rules,  since  asthmatic  patients,  above  all  others,  have  the  strongest 
idiosyncrasies  with  reference  to  certain  localities  and  certain  climates;  a 
climate  or  locality  that  may  benefit  one  may  fail  to  give  relief  to  another. 
These  patients,  as  a  rule,  do  well  in  high  and  dry  altitudes,  unless  they 
have  chronic  emphysema.  Experience  alone  will  determine  the  best  lo- 
cality for  the  individual  asthmatic  patient.  It  is  a  good  rule,  however, 
to  avoid  the  locality  in  which  the  attack  developed,  especially  at  the  sea- 
son of  the  year  when  attacks  are  liable  to  occur.  If  the  attack  has  developed 
in  the  city,  a  change  to  the  country  is  advisable,  and  vice  versa.  If  the 
attacks  are  worse  in  winter,  or  if  they  are  precipitated  by  recurring  at- 
tacks of  bronchitis,  it  is  advisable  to  spend  the  cold,  damp  months  of  the 
year  in  some  such  climate  as  that  of  northern  California  or  Florida. 

It  may  be  well  to  note  that  patients  suffering  from  an  asthmatic  con- 
stitution "are  not  good  subjects  for  the  serum  treatment  commonly  used 
in  certain  acute  infections,  such  as  diphtheria  and  sepsis.  Sudden  prostra- 
tion and  sometimes  death  may  result  from  the  use  of  serum  in  these  cases. 


SECTION   XII 

DISEASES   OF   THE   EAR 

CHAPTER    LXXXIII 
OTITIS   MEDIA  AND   MASTOIDITIS 

OTITIS  MEDIA 

Etiology. — This  disease  is  more  comnion  in  infancy  and  childhood  than 
later  in  life.  The  reasons  for  this  may  be  found  in  the  fact  that  the 
Eustachian  tube  at  this  time  is  shorter,  larger,  more  patulous  and  opens 
lower  in  the  pharynx  than  in  the  older  child,  and  that  the  acute  infectious 
diseases  and  acute  pharyngitis,  of  which  otitis  media  is  a  complication,  are 
more  frequent  during  this  period. 

The  essential  cause  of  otitis  media  is  an  infection  of  the  middle  ear 
with  bacteria  which  have  found  their  way  from  the  pharynx  through  the 
Eustachian  tube.  Staphylococci,  streptococci,  pneumococci,  and  influenza 
bacilli  are  the  most  common  microorganisms  producing  this  condition. 
Diphtheria,  tubercle,  typhoid  and  the  pyocyaneus  bacilli  may  occasionally 
act  as  exciting  factors.  Some  of  these  microorganisms  are  usually  found 
on  the  normal  mucous  membranes  of  the  nose  and  pharynx,  or  in  the  crypts 
and  fissures  of  chronically  enlarged  tonsils  and  adenoids.  This  is  one  of 
the  important  reasons  why  otitis  media  is  such  a  common  complication  of 
acute  pharyngitis,  tonsillitis,  influenza,  epidemic  grippe,  measles,  scarlet 
fever,  diphtheria,  pneumonia,  bronchopneumonia,  whooping-cough,  gastro- 
enteritis, congenital  syphilis,  and  typhoid  fever.  In  fact,  any  disease 
which  lights  up  an  acute  inflammation  of  the  nasopharynx,  or  which  great- 
ly reduces  the  vitality  and  resisting  power  of  the  individual  child  against 
catarrhal  diseases,  may  be  complicated  or  followed  by  an  acute  otitis 
media.  Some  of  the  microorganisms,  such  as  the  influenza  bacillus  and 
the  pneumococcus,  which  are  distinctly  related  to  definite  acute  infec- 
tious processes,  may  have  a  special  predilection  for  producing  otitis  media. 
When  infection  is  present  in  the  pharynx  this  disease  may  rarely  be  pro- 
duced by  swimming  under  water,  by  douching,  and  by  blowing  the  nose. 
In  such  cases  the  infection  is  forced  from  the  pharynx  through  the  Eus- 
tachian tube  into  the  middle  ear. 

Symptomatology. — Otitis  media  is  almost  always  a  secondary  disease. 

714 


OTITIS    MEDIA  715 

It  is  frequently  masked  by  the  infection  of  which  it  is  a  complication, 
and  its  onset  may  be  obscured  or  modified  somewhat  by  the  presence  of 
fever,  pain  and  other  symptoms  due  to  other  causes.  In  the  majority  of 
instances,  however,  the  onset  is  announced  by  a  sudden  and  marked  rise 
of  temperature  following  an  attack  of  influenza  or  some  other  acute  in- 
fection. The  temperature  in  a  few  hours  may  reach  104°  or  105  °F.,  and 
is  usually  associated  with  more  or  less  earache,  indicated  by  the  crying 
and  fretfulness  of  the  child.  In  some  cases,  however,  acute  symptoms  are 
absent,  and  the  first  manifestation  of  the  disease  is  a  discharge  from  the 
external  ear.  This  form  of  onset  may  occur  in  very  young  infants  and  in 
older  infants  suffering  from  congenital  syphilis,  chronic  glandular  tuber- 
culosis, or  chronic  gastrointestinal  disease.  In  these  cases  there  may  be 
no  fever  and  no  pain  during  the  course  of  the  disease,  or  the  fever  without 
the  pain  may  appear  following  the  perforation  of  the  eardrum  and  the 
discovery  of  the  discharge  from  the  ear.  In  other  cases  a  high  and  remit- 
tent fever  may  be  present  for  days  without  any  pain  or  other  symptoms 
to  call  attention  to  the  ear.  In  view  of  this  fact,  therefore,  it  is  a  wise 
precaution  to  carefully  examine  the  eardrum  and  pharynx  of  every  child 
suffering  from  obscure  fever.  Otitis  media  and  mastoiditis  are  among  the 
most  common  causes  of  unexplained  remittent  and  intermittent  fevers  in 
young  children.  In  rare  instances  these  temperatures  may  continue  for 
many  weeks  before  there  is  marked  evidence  either  in  the  eardrum  or  over 
the  mastoid  process  of  middle  ear  or  mastoid  infection. 

The  course  of  the  fever  in  otitis  media  is  variable.  It  commonly  con- 
tinues until  the  eardrum  is  perforated  by  the  pressure  of  the  fluid  from 
within  or  by  operative  measures  from  without.  Following  the  perfora- 
tion and  the  free  discharge  of  pus  the  temperature  falls,  and  if  the  drain- 
age from  the  internal  ear  remains  good  the  temperature  remains  at  or  near 
normal.  In  such  cases,  however,  a  secondary  rise  in  temperature  common- 
ly means  either  the  blocking  up  of  the  opening  in  the  eardrum  or  the 
extension  of  the  disease  to  the  mastoid  cells.  The  subsequent  course  of 
the  temperature  in  such  cases  will  depend,  on  the  one  hand,  upon  re- 
establishing the  drainage  from  the  middle  ear,  and,  on  the  other,  upon 
relieving  the  inflammation  in  the  mastoid  cells  by  operative  or  other 
measures. 

Earache  in  older  children  is  very  common,  and  only  in  the  minority 
of  cases  is  it  a  symptom  of  otitis  media,  but  when  it  continues  at  intervals 
for  more  than  twenty-four  hours  and  is  associated  with  an  unexplained 
elevation  of  temperature  it  indicates  middle-ear  inflammation.  It  is  diffi- 
cult in  a  child  not  old  enough  to  locate  pain  to  determine  the  existence 
of  an  earache,  but  it  may  be  suggested  by  unexplained  irritability,  sleep- 
lessness and  paroxysms  of  crying,  and  sometimes  the  child  by  its  position 
protects,  or  with  its  hand  reaches  for,  its  ear.  ,    ,      ■,. 

Otoscopic  Examination.— The  diagnosis  of  otitis  media  is  made  by  dis- 
covering  a  discharge  from  the  ear  or  by  a  careful  examination  of  the  ear- 
drum     The  difficulty,  however,  of  determining  the  existence  of  an  otitis 


716  OTITIS    MEDIA    AND    MASTOIDITIS 

media  from  an  examination  of  the  eardrum  is  ofttimes  so  great  that  a 
specialist  should  be  called  upon  to  determine  the  significance  of  the  find- 
ings of  such  an  examination.  The  child  with  its  arms  at  its  side  should 
be  wrapped  in  a  sheet,  and  its  body  and  head  firmly  held  by  an  assistant. 
The  operator  then  draws  the  auricle  downward  and  backward  and  inserts 
into  the  ear  a  speculum  of  proper  size  and  shape,  then  with  a  head-mirror, 
or  an  electric  head-light,  he  can,  by  illuminating  the  canal,  bring  the  ear- 
drum into  view.  It  may  be  necessary  before  making  this  examination  to 
cleanse  the  external  auditory  canal  with  a  fine  cotton-wrapped  probe.  In 
cases  of  otitis  media  the  drum  above  Shrapnell's  membrane  may  be  found 
congested,  reddened,  and  sometimes  bulging  slightly  outward.  If  perfora- 
tion has  already  occurred,  the  opening  may  commonly  be  seen  in  the  pos- 
terior quadrant. 

Prognosis. — The  prognosis  is,  as  a  rule,  good.  This  is  especially  true 
if  the  opening  in  the  eardrum  is  made  early  in  the  disease.  Where  mas- 
toiditis occurs  as  a  complication  the  prognosis  is  much  more  serious.  If 
the  middle-ear  inflammation  continues  through  lack  of  proper  drainage  and 
other  surgical  treatment,  hearing  may  be  impaired,  and,  in  some  instances, 
entirely  lost. 

Prophylaxis. — In  the  treatment  of  all  diseases  in  which  otitis  media 
is  a  common  complication,  earache  should  receive  prompt  and  careful 
attention,  and  the  eardrum  from  time  to  time  be  inspected.  Children 
who  have  enlarged  tonsils  and  adenoids,  and  who  have  suffered  from  ear- 
ache or  from  one  attack  of  otitis  media,  should  have  these  diseased  tissues 
removed  after  the  acute  attack  has  subsided. 

Treatment. — Earache,  which  is  commonly  an  early  symptom,  may  some- 
times be  relieved  by  hot  irrigations  of  normal  saline  solution.  This  may  be 
accomplished  by  inclining  the  child's  head  over  its  shoulder  and  intro- 
ducing into  the  ear  a  small  straight  glass  medicine  dropper  attached  to  the 
hose  of  a  fountain  syringe.  If  the  bag  holding  the  hot  saline  solution  is 
held  one  or  two  feet  above  the  child's  head,  a  steady  stream  of  hot  salt 
water  may  in  this  way  be  directed  into  the  ear.  Following  this,  hot  flan- 
nel, hop-bags,  or  water  bottles  may  be  applied.  If  these  measures  fail  to 
give  relief,  a  few  drops  of  warm  paregoric  may  be  dropped  into  the  ear, 
and  the  ear  plugged  with  warm  cotton-wool.  In  some  instances  the  pain 
may  be  so  great  that  paregoric  is  indicated  internally;  it  may  be  given  in 
from  5-  to  15-drop  doses,  according  to  age.  If  the  earache  continues,  and 
especially  if  it  be  associated  with  fever,  paracentesis  should  be  performed, 
even  though  the  eardrum  presents  little  indication  of  the  inflammation 
within.  Following  the  incision  a  serous,  seropurulent,  or  purulent  dis- 
charge makes  its  appearance,  sometimes  at  once;  in  other  cases  it  may  be 
delayed  for  twelve  or  more  hours.  The  character  of  the  discharge  may 
depend  upon  the  stage  of  the  inflammation;  in  well-marked  cases  which 
have  been  developing  for  a  number  of  days  it  is  always  purulent.  During 
the  acute  stage  the  child  should  be  confined  to  bed  and  the  external  audi- 
tory canal  frequently  irrigated  with  a  warm  mild  saline  antiseptic ;  follow- 


MASTOIDITIS  717 

ing  this  the  auditory  canal  should  be  dried  with  a  cotton-wrapped  probe 
and  a  small  roll  of  antiseptic  gauze  inserted.  A  piece  of  gauze  over  the 
external  ear  and  a  bandage  to  hold  this  in  place  complete  the  dressing. 
The  gauze  m  the  auditory  canal  absorbs  the  discharge  and  prevents  irrita- 
tion and  inflammation  of  these  external  parts.  These  details  are  most  im- 
portant in  treating  cases  where  the  discharge  is  irritating  or  where  it  lasts 
over  a  number  of  weeks.  If  the  child  is  otherwise  in  good  health  and  the 
drainage  from  the  internal  ear  is  satisfactory,  the  discharge  should  cease 
within  a  week  or  ten  days,  and  complete  recovery  follow.  In  cases,  how- 
ever, associated  with  syphilis,  tuberculosis,  or  other  forms  of  chronic  mal- 
nutrition, the  otitis  media  usually  continues  until  these  underlying  causes 
have  been  removed  by  proper  treatment.  In  such  eases  of  prolonged  mid- 
dle-ear suppuration  there  is  great  danger  that  the  hearing  may  be  impaired 
or  lost. 

MASTOIDITIS 

Etiology.' — Since  this  condition  is  nearly  always  secondary  to  acute  or 
chronic  otitis  media,  its  causative  factors  are  the  same  as  those  just  out- 
lined for  that  disease.  The  inflammation  spreads  from  the  middle  ear 
into  the  mastoid  cells,  and  causes  inflammation  and  necrosis  of  these  tis- 
sues. In  every  case  of  otitis  media  the  physician  should  constantly  be 
on  the  lookout  for  the  development  of  a  mastoiditis. 

Symptomatology. — Associated  with  the  symptoms  of  an  acute  otitis 
media  we  may  have,  as  indications  of  a  mastoiditis,  an  unexplainable  rise 
in  temperature.  That  is  to  say,  careful  otoscopy  may  show  that  the  open- 
ing in  the  drum  membrane  is  sufficiently  large  for  drainage,  and  may 
indicate  that  the  middle  ear  condition  is  improving,  and  yet,  notwith- 
standing these  facts,  a  septic  temperature  develops,  which  may  run  to 
104°  or  105°F.  some  time  during  the  day,  and  fall  below  normal  at  an- 
other. In  another  class  of  cases,  when  a  free  incision  of  the  drum  mem- 
brane followed  by  a  copious  discharge  of  pus  fails  to  clear  up  the  septic 
temperature,  mastoiditis  is  to  be  suspected.  The  diagnosis  is  confirmed  by 
finding  the  tissues  over  the  mastoid  slightly  reddened,  swollen,  and  tender 
to  the  touch.  Tenderness  above  the  tip  of  the  mastoid  can  usually  be 
elicited,  even  if  other  symptoms  are  absent.  In  making  pressure  care 
should  be  taken  to  press  backward,  so  that  the  soreness  which  comes  from 
the  middle-ear  inflammation  will  not  be  mistaken  for  that  due  to  mastoid- 
itis. In  many  of  these  cases  the  swelling,  pain  and  tenderness  in  the  mas-  ' 
toid  region  are  so  marked  that  the  diagnosis  can  scarcely  be  overlooked; 
in  others,  however,  the  onset  may  be  so  sudden  and  so  violent  that  ex- 
tensive necrosis  of  the  bone  has  occurred  before  the  physician  has  even  sus- 
pected the  presence  of  otitis  media. 

There  is  another  group  of  cases  very  obscure  and  very  insidious,  char- 
acterized by  septic  temperature,  which  may  run  for  weeks  witliout  there 
being  any  local  evidence  whatever  of  otitis  media  or  mastoiditis. 


718  OTITIS    MEDIA    AND    MASTOIDITIS 

Treatment. — The  treatment  of  the  otitis  media,  of  which  the  mastoid- 
itis is  a  complication,  should  be  continued  as  above  outlined.  Free  drain- 
age from  the  middle  ear  must  be  maintained.  Blood  may  be  withdrawn 
from  the  mastoid  region  by  leeches,  and  cold  applications  should  be  made 
with  small  ice-bags.  By  blowing  out  the  middle  ear  through  a  catheter, 
introduced  into  the  Eustachian  tube,  one  can  more  effectually  increase  the 
drainage;  this  operation,  however,  can  be  done  only  in  older  children.  If 
under  these  measures  the  septic  temperature  and  the  pain  and  tenderness 
do  not  begin  to  subside,  the  radical  operation  for  mastoiditis  becomes 
necessary.  Chronic  mastoiditis,  which  fails  to  yield  to  proper  surgical 
treatment,  may  have  as  its  underlying  etiological  factor  syphilis  or  tuber- 
culosis. Doubtful  cases  of  this  character  should  be  subjected  to  a  thor- 
ough course  of  antisyphilitic  treatment. 


SECTION   XIII 

DISEASES   OF   THE   SKIN 

CHAPTER   LXXXIV 
ECZEMA    AND    OTHEE    SKIN    DISEASES 

ECZEMA 

This  is  an  inflammation  of  the  skin  which  may  manifest  itself  in  an 
acute,  subacute,  or  chronic  form. 

Etiology. — It  is  more  common  in  infancy,  since  the  very  delicate  struc- 
ture of  the  skin  at  this  period  of  life  makes  it  especially  susceptible  to 
inflammation  from  irritants  of  any  kind,  and  the  unstable  condition  of  the 
vasomotor  nervous  system  makes  it  especially  liable  to  cutaneous  conges- 
tion, erythema,  and  inflammation  from  slight  causes. 

Any  agent,  chemical,  toxic,  infectious,  physical  or  mechanical,  which 
irritates  the  skin  and  is  sufficiently  intense  and  prolonged,  will  cause  ec- 
zema. It  matters  not  whether  this  irritation  comes  from  without  or  from 
within. 

Internal  Causes. — Hereditary  influences  are  important,  since  it  is 
not  uncommon  to  observe  this  disease  in  all  of  the  children  of  a  family, 
but  the  exact  character  of  this  hereditary  predisposition  cannot  always 
be  determined,  but  that  in  many  instances  it  may  be  gouty  or  neurotic  is 
beyond  question.  General  malnutrition  from  such  constitutional  disturb- 
ances as  glandular  tuberculosis,  syphilis,  rickets,  and  anemia  may  produce 
special  susceptibility  to  eczema.  It  is  also  stated  that  such  reflex  factors 
as  diseased  adenoids,  adherent  prepuce  and  dentition  may  be  exciting  fac- 
tors; the  importance  of  reflex  factors,  however,  has  been  greatly  exagger- 
ated, and  I  have  never  been  fully  convinced  that  they  deserve  a  place  among 
the  causative  factors  of  this  disease.  The  most  important  internal  causes  of 
eczema  are  undoubtedly  autointoxications  and  gastrointestinal  toxemias. 
Constipation,  gastrointestinal  indigestion,  and  food  idiosyncrasies  are  im- 
portant factors  in  many  cases.  It  may  be  a  very  difficult  matter  in  an  in- 
dividual case  to  determine  the  food  idiosyncrasy  which  is  producing  the 
eczema.  An  article  of  food  which  in  one  child  may  aggravate  or  even 
produce  an  eczema  will  in  another  have  no  such  influence.  It  is  a  fact, 
however,  that  overfeeding  is  one  of  the  common  factors  in  producing  this 
disease. 

47  719 


720  ECZEMA    AND    OTHER    SKIN    DISEASES 

External  Causes. — Among  the  most  important  of  those  tlie  follow- 
ing may  be  noted:  Irritating  soajjs,  rough  handling  of  the  tender  skin, 
perspiration,  the  rubbing  together  of  juxtaposed  skin  surfaces,  acid  urine, 
chafing  discharges  from  the  intestines  and  other  mucous  membranes,  irri- 
tating clothing,  exposure  to  extremes  of  heat  and  cold,  the  application  of 
certain  drugs  and  chemicals,  the  scratching  associated  with  parasitic 
skin  diseases,  and  other  causes  that  produce  itching,  and  the  inocula- 
tion of  the  skin  with  pathogenic  bacteria. 

The  character  of  the  eczema  depends  upon  the  severity  of  the  exciting 
cause  producing  the  irritation,  and  its  course  upon  the  length  of  time  that 
this  cause  is  active. 

Symptomatology. — Inflammation  of  the  skin  is  a  very  common  disor- 
der of  childhood.  It  usually  begins  as  a  congestion  or  erythema,  and  acute 
inflammatory  changes  follow,  which  may  produce  a  variety  of  lesions. 
These  acute  processes  may  be  erythematous,  papular,  vesicular,  or  pus- 
tular. These  various  forms  may  remain  distinct,  or  they  may  be  differ- 
ent stages  of  the  same  attack  of  eczema,  or,  in  other  cases,  the  various 
skin  lesions  may  be  more  or  less  commingled,  or  at  least  may  be  present  in 
different  parts  of  the  body  at  the  same  time. 

Erythema  is  very  frequently  found  where  opposed  surfaces  rub  one 
another,  such  as  the  groins,  the  neck,  and  the  axilla ;  it  is  also  very  com- 
mon on  the  face.  It  is  characterized  by  redness,  swelling,  and  infiltration 
of  the  skin,  and  later  one  of  the  typical  forms  of  eczema  may  develop. 

Papular  eczema  is  characterized  by  the  presence  of  small  red  papules, 
which  have  a  tendency  to  group  themselves  on  the  face  and  on  the  arms 
and  legs.  The  surrounding  skin  is  congested  and  the  papules  have  a  sliot- 
like  feel;  as  they  coalesce  they  may  produce  a  decided  thickening  of  the 
skin,  characterized  by  marked  redness  and  extreme  irritation. 

The  vesicular  type  is  characterized  by  the  formation  of  large  numbers 
of  small  vesicles,  which  may  coalesce  and  produce  large  vesicles  filled  with 
a  thick  serum,  which,  as  the  vesicles  break,  is  poured  out  and  dries  upon 
the  surface.  On  the  scalp  this  condition  is  known  as  seborrhea,  and  the 
whole  or  a  portion  of  the  hairy  scalp  of  the  infant  is  covered  with  a 
yellow  or  brownish  scab,  which  is  composed  of  the  dried,  yellowish  exu- 
date, cast-off  epithelium  and  hair.  When  this  dried,  scabby  material  is 
removed  it  leaves  a  red,  raw,  and  weeping  surface,  which,  after  a  time,  is 
again  covered  with  the  same  scabby  exudate.  A  vesicular  eczema  of  the 
face  and  of  the  arms  and  legs,  which  are  also  favoral)le  sites  for  this  dis- 
ease in  childhood,  is  of  the  weeping  variety,  and  portions  of  the  surface 
may  be  covered  by  a  thin  crust  which  is  easily  removed. 

The  pustular  form  is  characterized  by  the  presence  of  pustules;  it  may 
be  an  advanced  stage  of  the  vesicular  variety.  In  this  condition  the  pus- 
forming  organisms  play  an  important  part  in  the  pathological  process. 
It  may  be  one  of  the  stages  of  seborrhea  of  the  scalp  above  mentioned,  and 
occurs  most  commonly  on  the  hairy  scalp  and  on  the  face. 

Following  the  acute  stages  above  described  a  variety  of  forms  may  re- 


ECZEMA  721 

suit.  These,  however,  do  not  represent  any  particular  change  in  the  patho- 
logical })rocess,  and  therefore  require  no  detailed  description.  Eczema 
crustosuin  refers  to  the  formation  of  crusts  such  as  have  been  already 
described.  Eczema  squamosum  refers  to  a  subacute  variety  of  eczema  in 
which  there  is  a  scaly  formation.  Eczema  rubrum  refers  to  the  condition 
of  the  skin  which  occurs  in  vesicular  and  pustular  eczemas,  in  which, 
with  the  removal  of  the  crusts  or  scales,  the  superficial  layers  of  the  epi- 
thelium of  the  skin  are  also  removed,  and  the  lower  and  red  layers  are 
uncovered,  leaving  a  raw,  weeping  surface. 

In  all  forms  of  eczema  the  inflammatory  process  in  the  skin  is  accom- 
panied by  itching  and  burning.  This  symptom,  while  present  in  every 
form  of  eczema,  is  more  aggravated  in  the  papular  form.  It  causes  the 
child  to  scratch  and  rub  the  inflamed  parts  and  thereby  adds  to  the  in- 
fiammatory  process,  and  very  materially  interferes  with  the  curative  treat- 
ment of  this  disease. 

Eczema,  as  a  rule,  produces  no  constitutional  disturbance  unless  the 
greater  portion  of  the  body  of  the  child  is  involved.  In  most  cases  the 
child  is  well  nourished  and  continues  to  gain  in  weight  and  develop  along 
normal  lines.  In  those  instances  where  constitutional,  nervous,  or  gastro- 
intestinal disorders  are  associated  with  eczema,  these  conditions  are  a  cause 
rather  than  an  effect  of  the  eczema. 

Diagnosis. — Eczema  is  to  be  differentiated  from  other  inflammations 
of  tlie  skin.  The  greatest  difficulty  perhaps  arises  in  differentiating  papular 
and  pustular  syphilides  from  eruptions  of  the  same  character  produced  by 
eczema.  In  syphilis  the  skin  eruption  is  more  general,  less  acute,  is  asso- 
ciated with  little  or  no  itching,  and  other  evidences  of  syphilis  are  com- 
monly present  to  assist  in  the  differentiation.  Neglected  scabies  may 
produce  a  well-marked  eczema.  The  differentiation  of  scabies  associated 
with  eczema  can,  as  a  rule,  be  made  by  the  presence  of  the  initial  burrows 
and  by  the  clinical  history  of  the  condition  which  corresponds  in  its  onset 
to  that  of  scabies.  The  contagious  character  of  scabies  and  the  presence 
of  more  than  one  case  in  a  family  may  also  assist  in  the  differentiation. 

Prognosis.— The  prognosis  of  acute  eczema  in  infancy  and  childhood 
is,  as  a  rule,  good  in  those  cases  in  which  the  physician  has  the  cooperation 
of  a  conscientious  mother  or  nurse  who  will  faithfully  carry  out  every 
detail  of  treatment.  The  prognosis,  however,  in  subacute  and  chronic 
cases  especially  if  they  be  associated  with  some  nutritional  fault  or  chronic 
intestinal  disturbance,  is  not  so  good.  Many  of  these  cases,  in  spite  of  con- 
scientious treatment,  may  continue  for  many  months  or  even  years.  In 
these  cases  the  disease  may  be  greatly  improved  for  a  time,  only  to  have 
the  symi)toms  recur  from  undiscoverable  causes. 

Treatment.-GENERAL  Treatment.-Iu  undertaking  the  treatment  of 
a  case  of  eczema,  the  mother  or  nurse  must  be  made  to  understand  the 
importance  of  the  general  as  well  as  the  local  treatment.  A  careful  fam- 
ily  and  previous  personal  history  of  the  child  must  be  obtained,  in  order 
to  ascertain  whether  there  is  any  constitutional  taint,  hereditary  idiosyn- 


722  ECZEMA    AND    OTHER    SKIN    DISEASES 

crasy,  or  local  constitutional  disorder  on  the  part  of  the  infant  itself 
which  may  influence  the  eczema. 

If  the  infant  be  sturdy,  fat,  and  well  developed,  a  gouty  or  uric  acid 
diathesis,  if  it  can  be  established,  may  furnish  a  clue  to  the  constitutional 
treatment.  In  such  cases  it  is  of  the  utmost  importance  that  the  infant 
should  not  be  overfed.  Its  food  should  not  contain  more  calories  than 
necessary  to  maintain  its  nutrition.  It  is  also  of  the  greatest  importance 
that  constipation,  if  it  exists,  should  be  carefully  overcome.  This  may  be 
done  by  adding  to  the  child's  milk  a  sufficient  quantity  of  saturated  solu- 
tion of  phosphate  of  soda,  one-half  tablespoonful  perhaps,  to  each  bottle 
or  glass  of  milk.  Milk  of  magnesia  may  be  used  for  the  same  purpose. 
Alkalies,  such  as  bicarbonate  of  soda  and  lime  water,  are  also  of  value. 
Not  only  the  quantity,  but  the  character,  of  the  food  must  be  carefully 
scrutinized.  It  is  advisable  to  exclude  all  raw  fruit,  such  as  orange 
juice,  and  many  of  these  cases  are  materially  benefited  by  diminishing  the 
quantity  of  sugar  taken.  A  sugar-free  diet  will,  in  some  instances,  mate- 
rially assist  in  bringing  about  a  cure.  Food  rich  in  sugar,  such  as  stewed 
prunes,  is  contraindicated,  and  it  is  also  advisable  to  use  as  little  sugar 
as  possible  with  the  cereal  foods  which  the  child  may  be  taking.  The 
"ready-to-serve"  cereals,  which  are  now  so  extensively  used  because  of  their 
judicious  advertisement,  are  contraindicated. 

If  the  infant  is  suffering  from  some  pronounced  malnutrition,  every 
attention  must  be  given  to  ascertaining  the  cause  of  this  constitutional 
disturbance  and  correcting  it.  If  the  child  be  rachitic  or  tuberculous, 
fresh  air,  cod-liver  oil,  and  a  properly  selected  diet  are  necessary  to  its 
cure.  In  every  case  of  eczema  it  is  absolutely  necessary  to  give  careful 
attention  to  the  gastrointestinal  canal.  If  anemia  be  present,  some  of  the 
malt  and  organic  iron  preparations  may  be  of  value.  In  addition  to 
these  general  rules  it  is  of  great  importance  in  subacute  and  chronic  cases 
to  study  the  food  idiosyncrasies  of  the  individual  child.  Some  clew  to 
this  may  be  had  by  inquiring  into  the  food  idiosyncrasies  of  other  mem- 
bers of  the  family,  and  then  again  it  may  be  discovered  that  certain  foods, 
such  as  oatmeal,  potatoes,  eggs,  and  sweets,  are  followed  by  relapses;  when 
this  is  the  case  such  foods  are  to  be  withheld  until  it  be  definitely  proven 
that  they  do  no  harm.  If  eczema  occurs  in  a  breast-fed  baby,  the  breast- 
milk  should  be  analyzed,  and  if  it  be  found  to  contain  an  excessive  quan- 
tity of  fat  or  protein,  the  diet,  exercise,  and  general  hygiene  of  the  wet- 
nurse  should  be  carefully  regulated  along  the  lines  outlined  in  the  chap- 
ter on  Breast-Feeding.  The  breast-milk  in  some  instances  may  be  so 
modified  as  to  materially  influence  the  course  of  the  eczema,  but  one  is 
never  justified  in  weaning  an  infant,  if  it  be  developing  along  normal 
lines,  simply  to  cure  its  eczema. 

In  cases  that  fail  to  yield  to  ordinary  methods  of  treatment,  such 
reflex  causes  of  nervousness  as  eye-strain,  adenoids  and  phimosis  should  be 
sought  for,  and  if  found  should  be  removed  by  appropriate  treatment. 
There  can  be  no  douljt  but  that  vasomotor  disturbances  may  aggravate  and 


ECZEMA  723 

prolong  an  eczema;  it  is  therefore  possible  that  reflex  factors  such  as 
those  above  named  may  act  in  this  way. 

In  the  treatment  of  eczema  it  is  of  the  greatest  importance  that  the 
inflamed  skin  should  not  be  irritated  by  frequent  washings  with  soap  and 
water,  and  above  all  that  the  child  should  be  prevented  from  scratching 
and  rubbing  the  inflamed  areas.  This  is  perhaps  the  most  difficult  part 
of  the  treatment;  the  pruritus  is  so  intense  in  many  of  tliese  cases  that, 
unless  the  child  be  constantly  watched,  it  will  manage  in  some  manner 
to  temporarily  relieve  the  itching  by  rubbing  the  inflamed  parts  against 
the  bed-clothing,  or  against  some  portion  of  its  body.  To  prevent  this  in 
eczema  of  the  face  and  scalp,  masks  and  bandages  are  so  applied  as  to 
cover  the  whole  inflamed  surface,  and  at  the  same  time  the  arms  are  in- 
cased in  stiff  sleeves  of  wicker  or  pasteboard,  so  that  the  child  cannot  reach 
the  inflamed  parts  with  its  hands.  Such  devices  in  an  individual  case 
must  be  left  to  the  ingenuity  of  the  physician,  it  being  understood  that 
an  important  part  of  the  treatment  is  the  prevention  of  the  scratching 
and  rubbing  of  the  inflamed  skin. 

Local  Applications. — Mild  inflammations  of  an  erythematous 
or  papulo-erythematous  type  may  be  successfully  treated  by  dusting 
powders,  soothing  lotions,  compresses,  and  sedative  ointments.  Cases 
of  the  papulovesicular  type  of  a  severe  and  acute  character  should 
be  treated  with  ice-cold  compresses  of  weak,  astringent,  or  boric  acid 
solutions. 

Cases  of  the  vesicular  type,  in  which  the  vesicles  have  ruptured  and 
the  surface  is  oozing,  should  be  treated  with  wet  compresses  or  with  oint- 
ments which  contain  a  sufficient  quantity  of  starch  or  zinc  oxid  to  absorb 
the  secretion  and  prevent  crust  formation.  When  the  inflamed  skin  is 
covered,  with  crusts,  these  should  always  be  softened  with  olive  oil  and 
gently  removed.  This  is  of  special  importance  when  the  hairy  scalp  is 
involved.  Long-standing  cases  in  which  there  is  more  or  less  infiltration 
of  the  skin  should  be  treated  by  stimulating  ointments  or  lotions  contain- 
ing salicylic  acid,  resorcin  and  tar.  Itching  should  be  combated  by  anti- 
pruritic lotions. 

Erythema  intertrigo  and  simple  forms  of  acute  eczema,  not  located 
on  the  hairv  parts  of  the  body,  may  be  successfully  treated  by  dusting 
powders  of  stearate  of  zinc,  or  of  equal  parts  of  oxid  of  zmc  and  starch. 
In  these  cases  Starten's  lotion  is  of  great  value. 

X     83 

R     Zinci    oxidi    ^  . 

'  3  IV 

Pulv.  calaimn£e  praep ^  . 

Glycerini §  vi 

Liquoris   calcis   ad 

S.     Shake  and  apply  freely  every  three  or  four  hours  to  the  inflamed  skin. 

Another  valuable  sedative  and  antipruritic  lotion  recommended  by 
Heidingsfeld  is  as  follows : 


724  ECZEMA    AND    OTHER    SKIN    DISEASES 

5     Potass,    sulphuret 3  ss 

Zinei  sulphat 3  ss 

Zinci   oxidi    3  v 

Aquae  calcis   3  vii  ss 

Aquas  dest.  q.  s.   td 3  vi 

This  preparation  should  he  shaken  and  applied  locally  every  four  hours 
by  means  of  an  ordinary  bristle  brush. 

These  lotions  are  not  only  sedative,  but  on  drying  they  leave  a  coating 
of  oxid  of  zinc  over  the  inflamed  parts. 

Ointments,  on  the  whole,  are  of  more  value  than  other  applications 
in  the  treatment  of  eczema;  to  obtain  good  results,  however,  it  is  of  the 
utmost  importance  that  they  should  be  properly  made,  and  that  the  ma- 
terials of  which  they  are  composed,  especially  the  bases,  should  be  fresh; 
if  they  are  prepared  with  decomposing  bases,  containing  fatty  acids  and 
other  irritating  materials,  they  may  do  more  harm  than  good.  The  milder 
ointments  used  in  the  treatment  of  acute  eczema  should  be  applied  on 
strips  of  lint  or  other  soft  material  to  the  inflamed  skin,  and  held  there 
by  appropriate  bandages.  In  eczema  of  the  face  and  scalp  a  well-fitting 
mask  for  the  face,  and  hood  for  the  scalp,  best  serve  the  purpose  of  hold- 
ing the  ointment  in  position  and  preventing  irritation  of  the  part  by 
scratching  and  rubhing.  In  the  chronic  and  subacute  forms  of  eczenui, 
in  which  stronger  and  stimulating  ointments  may  be  required,  it  is  best 
to  make  the  application  by  lightly  rubbing  the  unguent  into  the  inflamed 
part;  the  degree  of  reaction  which  follows  such  an  application  will  de- 
termine whether  a  stronger  ointment  is  to  be  used;  if  the  reaction  is 
marked  and  the  inflammation  of  the  skin  is  increased  by  such  an  applica- 
tion, then  the  milder  ointments  suitable  for  the  treatment  of  acute  eczema 
are  to  be  used  for  allaying  this  irritation.  Hardaway  and  Grindon  say: 
"As  a  routine  prescription  in  almost  all  types  of  eczema  in  children,  es- 
pecially eczema  rubrum,  the  following  prescription  has  the  widest  range 
of  usefulness: 

IJ     Zinci    oxidi    3  i 

Pulv.  amyli    3  H 

Ung.  pieis  liq 3  ii 

Ung.  vaselini   plumb,   q.   s.   ad |  i 

"In  warm  weather  the  amount  of  starch  may  be  increased.  In  place 
of  the  tar,  3  or  3  minims  of  carbolic  acid  jnay  be  added  to  each  ounce ;  and, 
instead  of  the  oxid  of  zinc,  an  equivalent  quantity  of  boric  acid.  In  most 
cases,  however,  the  formula  as  given  is  the  best." 

In  beginning  the  treatment  a  sedative  ointment  should  be  prescribed : 

IJ     Bismuth   subnit 3  ii 

Zinci    oxidi    3  ss 

Glycorini     3  iaa 

Acidi  carbolici    ni  xx 

Vaselini  ad |  ii 


ECZEMA  725 

Hebra's  formula  is  an  excellent  one  in  some  cases: 

3     Emplastri  diachyli   5  i 

Vaselini    |  i 

Another  formula  of  equally  wide  range  of  usefulness,  very  generally 
and  almost  universally  employed  in  all  types  of  eczema  where  there  is  a 
tendency  toward  vesiculation  or  oozing,  is  the  well-known  salicylatcd  paste 
of  Lassar: 

IJ     Acidi  salicylici    grs.xxx 

Zinci  oxidi   3  vi 

Starch     3  vi 

Vaselini |  ii 

In  cases  where  there  is  a  suspected  local  infection  of  staphylococcic 
nature,  either  of  etiologic  or  of  incidental  character,  the  sulphur  salicy- 
lated  paste  of  Lassar  can  be  used  with  most  gratifying  results: 

IJ     Zinci  oxidi      3  V 

Starch     3  v 

Sulphur     3  ii 

Acidi  salicylici .grs.xxx 

Petrolatum     3  u 

In  all  cases  where  itching  is  a  more  or  less  intolerant  feature,  the  fol- 
lowing well-known  lotion  can  be  used  in  connection  with  other  treatment : 

IJ     Liq.  carbonis  '  '  ^ 

Aquaa   dest 2  vi 

Sig.     Apply  every  few  hours  to  allay  itching. 

In  subacute  eczema  the  following  is  used  to  remove  the  scales  and  stop 
the  itching,  and  it  may  be  followed  by  one  of  the  milder  ointments  above 
given : 

R     Zinci  oxidi   

3  li 
Ung.  picis  liquidse   "^  „ 

Ung.    aqua}   rosa)    _  . 

TV-  2  IV 

Lanolini    

The  following  bland  paste,  which  dries  and  is  easily  washed  off,  may 

also  be  recommended: 

3  ii 

3     Zinci  oxidi   ,  jj 

Pulv.  amyli '.'..'.'.........    ^.  xv 

Acidi  salicylici »  j 

Ung.  aqua)  rosse  


726  ECZEMA    x\ND    OTHEE    SKIX    DISEASES 

In  the  treatment  of  seborrhea  of  the  scalp  the  crust  is  to  be  thoroughly 
moistened  with  olive  oil,  which  may  be  applied  on  strips  of  lint  which  are 
held  in  position  by  a  skull  cap.  After  twelve  or  twenty-four  hours  of  such 
an  application,  the  crust  is  to  be  carefully  removed  without  tearing  or 
irritating  the  inflamed  skin,  and  the  following  ointment  is  then  to  be 
applied : 

IJ     Acidi   salicylici    3  i 

Sulphuris   praecip 3  ss 

Ung.    aquae   rosas   q-s    §  i 

URTICARIA 

Urticaria  is  a  vasomotor  neurosis,  characterized  by  intense  pruritus 
and  presenting  a  more  or  less  characteristic  skin  eruption.  It  is  com- 
monly called  hives  or  nettlerash. 

Etiology. — The  important  predisposing  etiological  factor  is  an  exag- 
gerated instability  or  excitability  of  the  vasomotor  nervous  system,  which 
creates  in  the  individual  a  special  susceptibility  on  the  part  of  this  sys- 
tem to  respond  to  the  reflex,  toxic  and  other  exciting  factors  of  this  dis- 
ease. These  factors  by  their  action  on  the  susceptible  vasomotor  nervous 
system  produce  a  localized  congestion  of  the  part  affected,  associated  with 
an  edema  due  to  serous  exudation.  The  excitability  of  the  vasomotor  nerv- 
ous system  may  be  hereditary,  as  urticaria  is  not  infrequently  a  family 
affection,  or  it  may  be  acquired  as  the  result  of  disease,  improper  feeding, 
or  bad  hygienic  surroundings. 

Urticaria  in  childhood  is  very  commonly  associated  with  gastrointestinal 
disturbances,  and  especially  with  acid  fermentations  from  overfeeding  with 
fats,  starches  and  sugars.  Certain  articles  of  diet,  such  as  strawberries, 
acid  fruits,  shell-fish,  oatmeal,  and  preserved  meats,  may  precipitate  an 
attack  without  producing  any  apparent  gastrointestinal  disturbance.  In- 
testinal worms,  undigested  food,  reflex  excitants,  insect  bites,  and  injury 
to  the  skin  may  be  exciting  causes.  Diphtheria  antitoxins  and  other 
serums  may  be  followed  by  an  attack  of  urticaria. 

Symptomatology. — Intense  pruritus  occurring  suddenly  without  appar- 
ent local  cause  on  the  part  of  the  skin  is  the  most  characteristic  symptom. 
In  a  severe  attack  of  acute  urticaria  the  suffering  produced  by  the  intense 
itching  may  be  almost  unbearable;  in  milder  cases,  and  fortunately  these 
are  much  more  common,  the  severe  itching  is  confined  to  small  portions 
of  the  body,  and  is  of  short  duration. 

The  Eruption. — The  most  common  urticarial  eruption  in  childhood 
is  composed  of  small  red  papules  (urticaria  papulosa) ,  which  may  be  wide- 
ly scattered  over  the  surface  of  the  body  or  confined  to  one  part.  This 
eruption  is  associated  with  such  intense  pruritus  that  the  skin  is  usually 
torn  and  injured  by  scratching;  a  complicating  eczema  may  thus  be  pro- 
duced. In  children  the  eruption  may  also  present  the  appearance,  as  it 
so  commonlv  does  in  the  adult,  of  wheels  with  red  circumferences  and 


URTICARIA  727 

paler  centers.  These  wheels  are  elevated  and  the  indurated  and  edematous 
thickening  can  be  felt  with  the  finger.  This  is  the  ordinary  nettlerash. 
This  character  of  eruption  may  be  so  grouped  as  to  produce  a  general  red- 
ness and  swelling  extending  over  a  large  portion  of  the  body;  when  the 
face  is  involved  the  features  may  be  distorted  and  the  eyes  closed.  Rarely, 
urticaria  is  associated  with  a  formation  of  vesicles,  and  hemorrhages  may 
occur  in  the  wheels  or  papules.  The  pruritus  and  eruption  may  disap- 
pear from  one  part  of  the  body  to  reappear  at  once  in  another.  Even  in 
acute  attacks  the  symptoms  may  abate  and  be  exacerbated  from  time  to 
time  over  a  period  of  days  or  weeks,  but  in  the  great  majority  of  cases 
the  attack  is  of  much  shorter  duration-.  In  the  subacute  and  chronic 
forms  of  this  disease  the  attacks  may  continue  for  weeks  at  a  time,  and 
may  recur  at  frequent  intervals  from  slight  or  undiscoverable  causes. 

Urticaria  of  Mucous  Membranes. — If  the  respiratory  mucous  mem- 
branes are  attacked,  coryza,  sibilant  bronchitis,  severe  dyspnea,  or  violent 
asthma  may  result.  If  the  gastrointestinal  mucous  membrane  is  affected 
a  colliquative  diarrhea  may  occur,  continue  for  a  number  of  hours,  and 
then  subside  without  medical  treatment.  These  syndromes  on  the  part 
of  the  respiratory  and  gastrointestinal  mucous  m.embranes  may  be  fol- 
lowed or  preceded  by  attacks  of  urticaria  of  the  skin. 

Progpiosis. — In  the  acute  forms  the  prognosis  is  good,  inasmuch  as  the 
cause  can  usually  be  located  and  the  symptoms  readily  controlled.  Chronic 
urticaria  may  persist  for  years,  resisting  the  most  careful  treatment. 

Treatment. — This  should  be  begun  by  a  dose  of  castor  oil  or  some  saline 
cathartic.  Following  this,  bicarbonate  of  soda  should  be  given  internally 
and  carbolic  acid  in  some  form  applied  to  the  skin  to  relieve  the  itching. 

IJ     Acidi   carbolic!    5    ^ 

Zinci    oxidi    • 3  S8 

Pulv.   calaminse   praep 3  iv 

Glycerini    3  i 

liquor    calcis    3  vii 

The  above  prescription,  together  with  the  one  which  follows,  is  recom- 
mended by  Hardaway  and  Grindon  to  relieve  the  pruritus  of  urticaria: 

B     Mentholis    ^  " 

Alcoholia     ^' 

Acidi  carbolici    ^  ^. 

Lotionis  zinci  oxidi  comp 3  vi 

These  lotions  are  to  be  applied  freely  with  a  soft  rag. 
Bromid  of  potash,  phenacetin,  or  antipyrin,  in  proper  doses,  may  relieve 
the  general  nervous  irritability  and  add  much  to  the  comfort  of  the  pa- 

^'''^The  above  treatment  applies  to  the  relief  of  the  immediate  attack 
but  the  most  important  part  of  the  treatment  is  yet  to  follow,  and  that 


728  ECZEMA    AND    OTHER    SKIN    DISEASES 

pertains  not  alone  to  the  satisfactory  convalescence  from  the  acute  attack, 
but  to  the  prevention  of  subsequent  attacks.  As  a  guide  to  tbis  end  the 
individual  case  should  be  carefully  studied  to  discover  the  exciting  causes 
of  the  attack  and  the  food  idiosyncrasies  of  the  patient.  If  no  cause  other 
than  general  nervous  irritability  associated  with  some  malnutrition  is 
discovered,  then  the  treatment  should  be  fresh  air,  a  carefully  selected 
diet,  outdoor  exercise,  quiet  surroundings,  and  such  tonics  as  tlie  individual 
case  may  demand.  These  may  include  cod-liver  oil,  iron,  or  arsenic.  In 
recurring  urticaria  it  is  most  important  that  the  patient  should  be  treated 
for  the  underlying  neurosis.  In  the  great  majority  of  cases,  however,  one 
is  able  to  find  some  acute  gastrointestinal  disturbance,  or  some  food 
idios3'ncrasy,  which  has  acted  as  the  exciting  cause.  Following  the  pre- 
liminary cathartic,  gastrointestinal  disturbances  are  to  be  treated  by  a 
diet  carefully  selected  to  come  within  the  range  of  the  physiological  di- 
gestive capacity  of  the  individual  child.  As  a  matter  of  routine,  oatmeal, 
orange  juice,  raw  fruits  of  all  kinds,  shell-fish,  fish,  pastry,  and  sweets  are 
to  be  carefully  avoided.  In  the  treatment  of  chronic  and  subacute  cases 
it  is  of  importance  to  remember  that  some  of  these  cases  respond  to  a 
sugar  or  fat-free  diet,  making  a  satisfactory  recovery  when  the  cream  is 
taken  off  the  milk  and  saccharin  is  used  instead  of  sugar.  It  has  been 
my  custom  in  troublesome  cases  to  place  the  child  upon  skimmed  milk.  If 
the  urticaria  is  controlled  by  this  diet,  then  from  time  to  time  other 
articles  of  food  are  carefully  added,  until  following  the  giving  of  some 
article  of  food  an  attack  of  urticaria  is  produced.  Only  by  some  such 
careful  method  as  this  can  the  physician  arrive  at  the  particular  food 
idiosyncrasy  which  may  be  an  important  factor  in  continuing  this  trouble- 
some disease. 

Certain  intestinal  antiseptics,  such  as  salol,  wintergreen  sodium  sali- 
cylate, and  carbonate  of  guaiacol,  may  be  of  value  in  those  cases  which  are 
produced  by  gastrointestinal  toxemia. 

FURUNCULOSIS 

Symptomatology. — This  is  an  infectious  condition  characterized  by 
multiple  superficial  abscesses  of  the  skin  involving  the  sebaceous  glands  and 
spreading  to  the  cellular  tissue.  It  occurs  most  commonly,  and  the  ab- 
scesses are  much  more  severe  and  widespread,  in  malnourished  infants  than 
in  those  of  good  physique.  In  normal  well-developed  infants  with  better 
powers  of  resistance  the  abscesses  are  smaller,  fewer,  and  much  more  likely 
to  be  confined  to  the  sebaceous  glands.  In  malnourished  infants  the  cellular 
tissue  and  deeper  layers  of  the  skin  are  involved,  and  the  disease  is  much 
more  widespread  and  yields  much  less  readily  to  treatment.  In  the  milder 
cases  staphylococci,  especially  the  staphylococcus  pyogenes  aureus,  are  the 
infecting  organisms.  In  the  more  severe  cases  streptococci  take  part  in 
the  destructive  process.  The  furuncles  are  commonly  located  on  the  scalp, 
forehead  and  neck,  and  in  the  severe  cases  may  be  widely  disseminated  over 


ERYTHEMA    MULTIFORME  729 

the  body.  They  may  vary  from  a  pea  to  a  walnut  in  size,  and  may  be 
very  superficial,  or  may  penetrate  beneath  the  deep  layers  of  the  skin.  The 
affection  is  not  characterized  by  constitutional  symptoms,  except  in  rare 
instances,  where  it  results  in  a  general  sepsis.  The  anemia,  malnutrition, 
and  general  feebleness  of  constitution  which  are  present  in  the  worst  eases 
are  predisposing  causes  rather  than  symptoms  of  this  disease. 

Prognosis. — This  is  good,  except  in  those  rare  cases  where  a  general 
sepsis  follows. 

Treatment. — The  underlying  constitutional  condition  in  malnourished 
children  requires  fresh  air,  careful  feeding,  and  appropriate  tonics,  such 
as  cod-liver  oil  and  the  malt  and  iron  preparations.  Calcium  sulphid  in 
14-  to  i/o-grain  doses,  three  times  a  day,  is  very  generally  recommended. 
The  local  treatment  consists  in  thoroughly  cleansing  the  skin  with  a  warm 
bath  of  soap  and  water,  and  then  incising  the  abscesses.  In  malnourished 
children  having  many  large  abscesses  it  is  better  not  to  open  all  of  these 
at  once.  The  abscesses  are  to  be  carefully  drained,  and  a  second  general 
bath  is  to  be  given  for  the  purpose  of  cleansing  the  skin.  Following 
this,  the  wounds  are  to  be  dressed  with  a  moist  antiseptic  solution,  such 
as  1  to  10,000  bichlorid  of  mercury.  A  mild  sulphur  ointment,  10  or  15 
grains  to  the  ounce  of  lanolin,  is  a  valuable  remedy  in  the  after-treatment 
of  these  abscesses,  or  Vleminckx  solution  may  be  used: 

5     Calcis    3  iv88 

Sulphur  floris   3  ix 

Aquae     I  ''^ 

M.    Boil  to  one-half  pint,  let  stand  24  houra.     Filter, 
Sig.  Paint  locally  with  bristle  brush  once  or  twice  a  week. 

If  the  skin  of  the  child  is  kept  clean  and  proper  attention  is  given  to 
its  general  health,  this  treatment  will  in  a  short  time  result  in  permanent 
recovery.  In  the  few  cases,  however,  which  resist  this  treatment  "staphylo- 
coccus vaccine"  may  be  used.  The  vaccine  treatment  of  chronic  furuncu- 
losis  is  followed  by  very  good  results.  The  autogenous  vaccines  are  to  be 
preferred  in  all  cases,  but  where  these  cannot  be  had  "stock  vaccines"  may 
be  used  as  recommended  under  Vaccine  Therapy. 

ERYTHEMA  MULTIFORME 

This  is  an  acute  inflammatory  disease  of  the  skin,  the  etiology  of  which 
is  not  definitely  kno^^oi.  It  is,  however,  believed  to  be  infectious.  In  many 
cases  it  is  apparently  closely  related  to,  or  caused  by  a,  gastrointestmal 
toxemia  Some  observers  believe  that  the  disease  is  at  times  a  rheumatic 
manifestation.     It  is  most  frequently  seen  during  the  winter  and  spring 

""'symptomatology.-An  erythema  appears  on  the  extensor  surfaces  of 
the  hands  and  feet,  and  gradually  spreads  upward  over  the  arms  and  legs 
and  may  finally  axtend  very  widely  over  all  parts  of  the  body.     In  the 


730  ECZEMA    AND    OTHER    SKIN    DISEASES 

beginning  the  eruption  is  pink  or  light  red  in  color,  and  gradually  be- 
comes a  darker  red.  As  a  rule  it  spreads  by  appearing  in  spots  along  the 
line  of  the  lymph  vessels;  these  red  spots  gradually  increase  in  size  and 
coalesce  with  neighboring  spots,  producing  a  more  or  less  extensive  ery- 
thematous patch,  which  commonly  has  less  color  in  the  center  than  it  has 
at  the  periphery.  Associated  with  these  thickened  erythematous  macules 
there  may  be  papules  and  vesicles.  This  multiform  eruption  of  macules, 
papules  and  vesicles  is  characteristic  of  this  disease.  Patches  of  purpura 
are  occasionally  seen.  There  is  a  sense  of  discomfort  with  little  or  no 
itching,  but  with  slight  fever  and  occasionally  tenderness  about  the  joints. 
Endocarditis  may  occur,  but  is  an  infrequent  complication.  Systolic  mur- 
murs may  be  heard  at  the  apex  of  the  heart. 

Gastrointestinal  symptoms  resulting  from  acute  indigestion  and  in- 
testinal toxemia  are  not  infrequently  associated  with  this  condition.  It 
must  be  remembered,  however,  that  there  is  a  form  of  simple  erythema 
due  to  gastrointestinal  toxemia,  which  is  quite  distinct  from  the  condition 
here  described. 

Prognosis. — This  is  favorable.  The  disease  runs  a  benign  course,  ter- 
minating in  recovery. 

Treatment. — If  gastrointestinal  disorders  be  present,  they  should  be 
treated  by  proper  diet  and  medicines.  But  even  in  those  cases  in  which 
there  is  no  evidence  of  intestinal  disorder,  the  treatment  should  be  begun 
by  clearing  the  intestinal  canal  with  calomel,  followed  by  castor  oil  or  a 
saline  laxative.  The  child  is  then  to  be  placed  upon  a  milk  and  cereal  diet, 
and  given  some  preparation  of  salicylic  acid,  such  as  aspirin,  salol,  or  win- 
tergreen  sodium  salicylate.  In  some  instances  there  is  little  doubt  but  that 
these  remedies  exercise  a  favorable  influence  upon  the  course  of  this  dis- 
ease. Sedative  ointments  containing  1  drachm  of  bismuth  or  15  grains 
of  oxid  of  zinc  to  the  ounce  of  lanolin,  should  be  used  to  relieve  the  irri- 
tation of  the  skin ;  if  itching  be  present,  10  minims  of  carbolic  acid  may  be 
added. 

CONGENITAL  ICHTHYOSIS 

The  etiology  of  this  condition  is  unknown.  It  is  congenital  and  heredi- 
tary. It  occurs  as  a  family  disease,  and  may  reappear  through  many 
generations. 

Symptomatology. — This  rather  rare  condition  makes  its  appearance 
in  early  infancy,  and  when  fully  developed  the  skin  presents  a  very  char- 
acteristic appearance.  It  is  dry,  thickened,  and  covered  with  fish-like 
scales.  These  horny,  closely  adherent  flakes  are  hard  and  brittle,  and 
cannot,  as  a  rule,  be  removed  without  causing  pain.  The  dried  skin  is 
broken  and  fissured,  especially  where  there  are  folds,  as  in  the  flexures  of 
the  joints.  This  eruption  is  most  characteristic  on  the  body  and  on  the 
extensor  surfaces  of  the  extremities. 

Prognosis. — This  is  unfavorable;  there  is  no  curative  treatment  for 
this  disease. 


IMPETIGO    CONTAGIOSA  731 

Treatment.— Tlic  palliative  treatment  consists  in  softening  and  remov- 
ing the  scales  by  sulphur  and  alkaline  baths.  Following  this  the  irritation 
of  the  skin  may  be  relieved  by  mild  sulphur  or  salicylic  acid  ointments, 
10  or  15  grains  to  the  ounce.  Mild  sedative  antiseptic  ointments  may  be 
used  for  softening  and  increasing  the  flexibility  of  the  skin. 

IMPETIGO  CONTAGIOSA 

Etiology.— This  is  an  inflammatory  condition  of  the  superficial  layers 
of  the  skin  produced  by  microorganisms.  Streptococci  and  staphylococci 
are  found,  but  the  specific  or- 
ganism of  this  affection  is  not 
at  the  present  time  definitely 
known.  It  is  a  distinctly  con- 
tagious disease,  characterized 
by  definite  lesions.  It  can  be 
transmitted  by  inoculation  from 
one  individual  to  another,  and 
is  readily  transferred  from  one 
part  of  the  body  to  another  by 
scratching.  The  fact,  however, 
that  such  inoculations  produce 
the  same  characteristic  lesions 
is  proof  of  the  specificity  of  the 
microorganism  which  causes 
the  disease.  It  may  occur  at 
all  ages,  but  it  is  much  more 
common  in  children  than  in 
adults. 

Symptomatology. — The  primary  eruption  occurs  in  the  form  of  thin 
watery  vesicles,  which  in  a  short  time  are  filled  with  seropurulent  or 
purulent  fluid.  These  pustules  break  and  the  exuded  matter  dries  and 
produces  a  yellow  scab,  which  is  attached  very  loosely  to  the  surface,  and 
is  surrounded  by  little  or  no  redness  of  the  skin.  Crops  of  vesicles  spring 
up  around  this  scab,  run  the  same  course,  and,  as  a  result,  a  large  portion 
of  the  face,  especially  about  the  angles  of  the  mouth  and  chin,  is  covered 
with  these  yellow  crusts.  As  the  scab  drops  off,  or  when  it  is  removed, 
the  underlying  skin  is  red  and  presents  a  raw,  moist  appearance.  The 
eruption  occurs  most  commonly  on  the  lower  portion  of  the  face,  and  may 
be  transferred  from  there  by  inoculation  to  other  portions  of  the  face,  to 
the  hairy  scalp,  and  to  the  hands.  These  uncovered  parts  are  most  likely 
to  be  infected,  but  other  parts  of  the  body  may  also  be  inoculated,  so  that 
the  disease  may  be  very  widespread.  At  times  the  scabbing  of  the  skin 
as  the  lesion  becomes  older  may  present  circular  or  oval  forms,  the  centers 
of  these  patches  having  healed.  It  is  scarcely  possible  to  mistake  this  form 
of  imijetigo  for  ordinary  eczema.    The  manner  of  its  spread  and  the  uni- 


FiG.  105. — Impetigo  Contagiosa. 
ingsfeld.) 


(M.  Held- 


732  ECZEMA    AND    OTHEE    SKIN    DISEASES 

forinity  with  which  it  presents  the  vesicle,  pustule  and  scab  should  make 
the  differentiation  plain. 

Treatment. — The  treatment  of  this  condition  is  simple  and  very  satis- 
factory. It  yields  very  readily  to  mild  sulphur  and  salicylate  ointments. 
In  beginning  the  treatment  the  crust  should  be  softened  with  oil,  lanolin, 
or  vaselin,  and  then  carefully  removed.  Sulphur  soap  may  be  used  for  the 
washing  of  the  diseased  part. 

Following  the  removal  of  the  scab  one  of  the  following  ointments  may 
be  applied: 

IJ     Acidi  salieylici    grs.  xv 

Zinci  oxidi ,  grs.  xv 

Vaselini    §  i 

IJ     Hydrargyri    ammoniati    grs.  vii 

Vaselini    3  iv 

Lanolini    3  iv 

Sig.  Apply  on  lint. 

PEMPHIGUS  NEONATORUM 

This  is  an  infectious  disease  of  the  skin  which  makes  its  appearance 
soon  after  birth.  It  is  characterized  by  the  appearance,  between  the  third 
and  the  tenth  day  of  life,  of  large  vesicles  or  cysts  varying  from  %  to  1 
inch  in  size.  These  vesicles  are  filled  with  a  cloudy  serum,  and  the  sur- 
rounding skin  is  usually  slightly  reddened.  As  the  thin  vesicles  break 
the  serum  dries  and  forms  a  thin  crust,  which,  on  removal,  leaves  a  red- 
dened raw  surface.  This  eruption  usually  appears  over  the  whole  body, 
with  the  exception  of  the  palms  of  the  hands  and  the  soles  of  the  feet. 
New  vesicles  appear  from  time  to  time,  the  disease  running  its  course 
in  five  or  six  weeks.  In  the  great  majority  of  cases  it  is  benign,  has  no 
constitutional  symptoms,  and  terminates  in  complete  recovery.  Occasion- 
ally, however,  the  disease  may  manifest  itself  in  a  more  malignant  type, 
being  associated  with  symptoms  of  general  sepsis.  These  cases  are  pro- 
longed, and,  as  a  rule,  terminate  fatally. 

Etiology. — It  is  believed  that  pemphigus  neonatorum  and  impetigo 
contagiosa  are  produced  by  the  same  contagion,  the  difference  in  the  ap- 
pearance of  the  eruption  depending  upon  the  age  of  the  child.  In  the 
newly  born  infant  it  presents  the  appearance  of  pemphigus  just  described, 
while  in  the  older  infant  and  child  the  clinical  symptoms  of  impetigo  are 
produced.  Staphylococci  and  streptococci  found  in  the  two  diseases  are 
similar,  and  inoculation  experiments  indicate  the  identity  of  the  two  con- 
ditions. The  specific  microorganism,  however,  of  this  infection  has  not 
been  clearly  demonstrated. 

Diagnosis. — The  characteristic  bullous  eruption  of  this  disease,  occur- 
ring as  it  does  only  during  the  early  days  of  life,  can  be  mistaken  only 
for   syphilitic  pemphigus.      In  this   latter   condition,   however,    the   blebs 


TINEA    TONSURANS  733 

are  most  commonly  found  on  the  palms  of  the  hands  and  the  soles  of  tlie 
feet.  This  fact,  with  other  symptoms  of  syphilis,  whicli  can  always  he 
found,  is  sufRcient  to  make  the  differentiation. 

Treatment. — The  great  majority  of  the  cases  require  little  treatment. 
The  skin  eruptions  may  be  treated  with  a  dusting  powder  of  stearate  of 
zinc  or  mild  antiseptic  ointments,  such  as  the  following : 

R     Bismuth   subnit 3  ) 

Acidi  borici   3  gg 

Lanolini   ad      |  ii 

Where  the  disease  is  associated  with  constitutional  symptoms,  the 
treatment  is  the  same  as  that  outlined  for  septic  infection  of  the  new- 
born. 

TINEA  TONSURANS 

Tinea  tonsurans,  or  ringworm  of  the  scalp,  is  a  contagious  disease 
caused  by  a  vegetable  parasite.  As  Saboraud  demonstrated,  this  parasite 
occurs  in  a  variety  of  species  which  produce  slightly  different  clinical 
syndromes.  This  form  of  tinea  is  confined  almost  exclusively  to  children, 
and  is  usually  spread  by  direct  contact;  it  may,  however,  be  conveyed 
through  articles  of  clothing 
and  toilet  utensils.  It  is  very 
frequently  seen  in  institu- 
tions and  families  in  epi- 
demic form. 

Symptomatology. — Ring- 
worm of  the  scalp  occurs  in 
round  or  oval  patches  which 
are  surrounded  by  a  slightly 
raised  and  reddened  ring. 
Toward  the  center  of  this 
ring  the  skin  grows  paler, 
and  the  hairs  within  the 
patch  are  stiff,  brittle,  broken 
off  near  the  skin,  and  sur- 
rounded by  a  whitish  scaly 
epithelium.  The  patch  in- 
creases in  size  in  all  direc- 
i-  1      11  1      •  Fig    106. — Alopecia  Accompanying  Ringworm  of 

tions,  gradually  producing  a    *^«-         ^^  g^^^^^    (M.  Heidingsfeld.) 

larger  ring,  which  approaches 

baldness.  The  same  child  may  have  more  than  one  patch  of  tinea,  and 
these,  by  enlarging,  may  run  together,  producing  one  large  irregular  patch 
with  rounded  ends. 

Diagnosis.— The  diagnosis  is  easily  made  by  the  presence  of  circular 
scaly  patches  having  a  reddened  circumference  and  containing  the  dry  and 
brittle  hair  stumps.    If  the  roots  of  one  of  these  diseased  hairs  be  exam- 


734  ECZEMA    AND    OTHEE    SKIN    DISEASES 

ined  under  the  microscope,  after  soaking  it  on  a  cover  glass  in  a  drop  of 
liquor  potassii,  the  small  spores  which  constitute  this  parasite  may  be  dis- 
covered. 

Treatment. — The  treatment  of  this  condition  is  entirely  local,  and,  on 
the  whole,  is  satisfactory,  although  many  cases  respond  very  slowly  to 
treatment. 

The  prophylactic  treatment  is  important.  Children  with  tinea  should 
not  be  allowed  to  go  to  school,  and  in  institutions  they  should,  if  pos- 
sible, be  isolated  from  other  children.  Where  isolation  is  not  possible, 
every  precaution  should  be  taken  against  the  spread  of  this  disease  by 
prohibiting  diseased  children  from  coming  in  close  contact  with  the  well 
ones,  and  by  seeing  that  each  child  suffering  from  tinea  has  his  own  comb 
and  hairbrush,  and  that  these  be  frequently  disinfected.  All  toilet  articles 
and  clothing  used  by  infected  children  should  be  carefully  boiled  and 
washed  before  they  are  used  by  other  children. 

In  beginning  the  treatment  the  hair  of  the  entire  head  should  be  close- 
ly cut  or  shaven.  In  girls  this  is  not  always  possible,  as  the  physician 
is  requested  to  make  an  attempt  to  save  the  hair;  in  such  cases  the  hair 
for  half  an  inch  around  the  patch  of  tinea  should  be  closely  cut.  After 
this  preparation  the  whole  scalp  is  to  be  carefully  washed  with  soap  and 
water,  and  afterward  with  a  saturated  solution  of  boracic  acid.  This 
washing  of  the  scalp  with  boracic  acid  is  to  be  done  daily  throughout  the 
treatment,  not  only  to  prevent  the  spread  of  the  disease  to  other  children, 
but  to  prevent  inoculation  of  other  portions  of  the  scalp  in  the  same  child. 

Sulphur  and  salicylic  acid  are  very  valuable  in  the  treatment  of  ring- 
worm. These  remedies  may  be  combined  in  the  same  prescription  as  fol- 
lows : 

IJ     Acidi   salicylic!    3  ss 

Sulphuris  praecip  3  i 

Vaselini    |  i 

Sig.  Kub  thoroughly  into  the  patch  morning  and  evening. 

This  ointment  is  also  of  great  value  in  ringworm  of  the  body,  which 
yields  very  readily  to  treatment. 

Chrysarobin  is  one  of  the  most  valuable  of  remedies  in  ringworm  of 
the  scalp.  It,  however,  must  be  applied  carefully  to  the  patch  and  subse- 
quent applications  are  to  be  decided  on  by  the  degree  of  reaction  which 
follows  the  first  application.  Sometimes  it  causes  an  acute  eczema  which 
contraindicates  its  use.  Hutchinson,  quoted  by  Hardaway  and  Grindon, 
recommends  the  following  formula : 

3     Chrysarobini    3  i 

Hydrarg.   ammoniati    grs.  xx 

Liq.   carbonis   deterg V[  x 

Lanolini    3  i 

Adipis    recentis 3  vi 


SCABIES  735 

They  also  say  tlie  following  method,  recommended  by  Crocker  "has 
given  good  results  in  our  hands."  The  patches,  as  well  as  a  surrounding 
strip  one-half  inch  wide,  are  closely  shaven,  after  which  they  are  painted 
with  collodion  containing  salicylic  acid,  1  to  30.  Fresh  collodion  is  ap- 
plied every  day  for  a  week.  The  dried  collodion  is  then  lifted  off  by  in- 
serting a  spatula  under  its  edge,  and  the  process  repeated  until  a  cure  is 
effected. 

Heidi ngsf eld  says  an  almost  unfailing  chrysarobin  ointment,  which 
should  be  applied  exceedingly  sparingly,  is  the  following: 

I^     Aeidi  salicylici  gj.g  ^^^ 

Acidi  pyrogalliei  3  j  gg 

Resoreini   ■,   ■ 

Chrysarobini   3   j  gg 

Sapo  viridis t  y 

Petrolati ?  v 

o  X 

Cases  that  do  not  yield  satisfactorily  to  the  above  treatment  should 
be  treated  by  the  X-ray;  when  this  is  properly  done  the  disease  commonly 
yields  very  readily.    A  permanent  and  comparatively  rapid  cure  is  effected. 

SCABIES 

Etiology.— Scabies,  or  the  itch,  is  a  contagious  disease  of  the  skin 
caused  by  the  acarus  scabiei  (itch-mite).  Thi§  parasite  burrows  between 
the  epithelial  layers  of  the  skin,  producing  a  thin  line  from  %  to  i/^  inch 
in  length,  which  can  readily  be  seen  through  a  small  magnifying  glass, 
and  may  be  made  out  by  the  naked  eye.  This  burrow  is  usually  slightly 
discolored  with  dirt,  especially  at  its  entrance,  and  at  its  end  a  yellowish 
opaque  object  (the  acarus)  and  a  pearly  white  vesicle  may  be  seen.  The 
acarus  may  be  lifted  from  its  burrow  on  the  point  of  a  needle  and  examined 
under  the  microscope ;  the  finding  of  the  itch-mite  is  absolute  proof  of  the 
existence  of  scabies.  The  diagnosis,  however,  is  commonly  made  by  the 
characteristic  burrows  above  described  and  by  the  intense  itching  which 
occurs  early,  continues  throughout  the  disease,  and  is  always  worse  at 
night.  These  pathognomonic  burrows  can  be  most  readily  found  between 
the  fingers  and  upon  the  wrists,  feet,  and  buttocks  of  the  child.  Very 
commonly  there  is  difficulty  in  finding  them  because  they  are  obscured  by 
the  secondary  inflammatory  lesions,  produced  in  part  by  the  irritation  of 
these  parasites,  but  largely  by  the  scratching  and  tearing  of  the  skin,  which 
are  unavoidable  on  account  of  the  intolerable  itching.  In  nearly  all  cases  a 
secondary  eczema  occurs,  characterized  by  the  formation  of  vesicles,  pa- 
pules and  pustules.  These  are  lacerated  by  scratching,  and  finger-nail 
marks  are  added  to  the  other  lesions,  and  the  serum  and  pus  dry,  pro- 
ducing crusts. 

Diagnosis. — In  advanced  cases  this  disease  may  bo  mistaken  for  ordi- 
nary eczema.  When  the  burrows  can  be  seen  and  the  parasites  found  the 
4§ 


736 


ECZEMA    AND    OTHER    SKIN    DISEASES 


diagnosis  is  easy.  But  even  when  this  is  not  possible  the  differential  diag- 
nosis between  the  two  conditions  can  usually  be  made  by  the  intense  pru- 
ritus which  charac- 
terizes scabies  from 
the  very  beginning 
of  the  disease,  and 
by  the  favorite  loca- 
tions of  the  two  con- 
ditions. A  history 
pointing  to  contagion 
is  also  important. 

Treatment.— The 
treatment  is  simple 
and  very  satisfac- 
tory; sulphur  applied 
in  the  form  of  an 
ointment  acts  spe- 
cifically in  the  cure 
of  this  disease.  Be- 
fore making  this 
application  all  per- 
sonal and  bed-cloth- 
ing should  be  steril- 
ized to  prevent  reinoculation  during  or  following  the  treatment.  The 
whole  surface  of  the  body  should  be  cleansed  with  soap  and  hot  water 
and,  after  thoroughly  drying  the  skin,  all  that  portion  of  the  body  on 
which  there  is  any  eruption  should  be  carefully  rubbed  with  sulphur  oint- 
ment— 1  drachm  of  sulphur  to  1  ounce  of  vaselin.  This  application 
should  be  made  before  going  to  bed,  and  the  next  morning  it  may  be 
removed  by  a  bath  of  soap  and  hot  water,  and  clean  clothes  put  on  for 
the  day.  This  treatment  is  to  be  repeated  three  or  four  niglits  in  succes- 
sion. It  may  then  be  discontinued  for  a  few  days,  and  again  repeated 
for  two  nights  in  succession;  by  this  time  a  permanent  cure  is  usually 
effected  so  far  as  the  destruction  of  the  acaries  is  concerned,  but  the  asso- 
ciated eczema  may  require  treatment. 


Fig.  107. — Pustular  Scabies  of  the  Hands 
ingsfeld.) 


(M.  Heid- 


PEDICULOSIS  CAPILLITII 

Etiology. — This  condition  is  caused  by  the  pediculus  capitis,  or  head 
louse,  which  is  1  to  2  mm.  in  length  and  has  attached  to  its  head  a  sharp 
proboscis  through  which  it  feeds  by  imbedding  it  in  the  scalp.  This  pro- 
duces the  intense  itching  which  is  characteristic  of  this  condition,  and 
causes  the  child  to  scratch,  tear,  and  mutilate  the  already  irritated  scalp. 
The  irritation  caused  by  the  louse,  together  with  the  traumatism  produced 
by  the  scratching,  may  cause  an  inflammation  of  the  skin  (eczema),  which 
is  confined  to  the  hairy  scalp.     This  parasite  is  very  prolific  and  fastens 


PEDICULOSIS    CAPILLITII  737 

its  eggs  in  great  numbers  to  the  hairs;  these  may  be  readily  seen  as 
grayish-white  scales  rather  firmly  attached  to  the  hair.  They  may  be  dis- 
tinguished from  dandruff  scales  by  the  fact  that  they  cannot  be  removed 
by  brushing. 

The  eczema  produced  by  this  condition  is  characterized  by  much  more 
itching  than  is  ordinary  eczema  of  the  scalp.  The  lymphatic  glands  in  the 
occipital  region  are  enlarged  in  aggravated  cases. 

Treatment. — In  hospital  cases  the  hair  should  be  closely  cut;  in  pri- 
vate practice,  however,  the  condition  is  usually  discovered  before  a  well- 
pronounced  eczema  has  resulted,  and  the  cutting  of  the  hair  is  not  neces- 
sary. 

The  treatment  consists  in  saturating  the  hair  with  coal-oil.  This 
may  be  done  by  carefully  rubbing  it  in  with  a  cloth.  When  the  hair  is 
thoroughly  soaked,  a  skull  cap  is  applied  covering  the  whole  hairy  scalp; 
the  next  morning  the  oil  is  washed  out  with  soap  and  water  and  the  hair 
dried.  If  the  associated  eczema  persists,  it  may  require  treatment,  but, 
as  a  rule,  with  the  removal  of  the  cause  the  inflammation  of  the  skin  is 
quickly  cured. 

Heidingsfeld  says:  "It  is  essential  for  the  successful  treatment  of 
pediculosis  capillitii  that  one  should  bear  in  mind  that  the  developing 
larvae  are  not  destroyed  by  the  antiseptics  which  are  successful  in  re- 
moving insects  which  have  been  hatched.  The  larvge  are  encased  in  im- 
pervious keratin,  and,  after  an  interval  of  seven  to  fourteen  days,  there 
will  be  a  fresh  crop  of  new  insects.  These  must  be  destroyed  by  a  repeti- 
tion of  the  treatment.  The  larvae  are  attached  to  the  hair  by  means  of 
a  calcareous  cement.  This  is  readily  dissolved  by  ordinary  vinegar  or  a 
ten  per  cent,  solution  of  acetic  acid.  The  live  insects  and  the  larvae, 
however,  can  be  removed  at  the  same  time  by  saturating  the  hair  with 
compresses  of  1-200  bichlorid  in  vinegar,  for  six  or  eight  hours.  The 
bichlorid  destroys  the  live  insects  and  the  larvae  are  loosened  from  the 
hair  by  the  vinegar,  so  they  can  be  readily  removed  by  means  of  a  fine 
comb." 


INDEX 


Abdomen,  examination  of,  in  illness,  30. 

Abscess,  of  brain,  617;  deep  bone,  com- 
plicating typhoid  fever,  274;  of  liver, 
complicating  lobar  pneumonia,  448;  of 
lymph  glands,  complicating  vaccinia, 
353;  periesophageal,  157;  perineph- 
ritic,  590;  peritonsillar,  421;  retro- 
pharyngeal, 427. 

Abt,  on  renal  and  vesical  irritation  fol- 
lowing use  of  urotropin,  587. 

AcABUs  scabiei,  735. 

Acetate  of  potash.  See  Potassium  ace- 
tate. 

Acetone  group,  presence  of,  in  urine, 
565;    in  recurrent  vomiting,  255. 

AcETONURiA,  565;  diagnosis  of,  566;  eti- 
ology of,  565;  in  measles,  336;  progno- 
sis of,  566;  treatment  of,  567;  in  ty- 
phoid fever,  273. 

Acidosis,  in  recurrent  vomiting,  252,  255. 

Adams,  report  by,  of  recoveries  from  sep- 
tic endocarditis,  491. 

Ad^nie.     See  Hodghin's  disease. 

Adenitis,  cervical,  in  scarlet  fever,  321; 
treatment  of,  331. 

Adenitis,  simple,  542;  definition  of, 
542;  diagnosis  of,  544;  etiology  of, 
542;  microorganisms  present  in,  542; 
symptomatology  of,  543;  treatment  of, 
544. 

Adenoids,  424;  cough  caused  by,  mis- 
taken for  whooping  cough,  291;  diag- 
nosis of,  426;  etiology  of,  425;  fre- 
quency of,  425;  history  of  knowledge 
concerning,  424;  method  of  examining, 
426;  as  cause  of  pavor  nocturnus,  672; 
sources  of  infection  in,  425;  sympto- 
matology  of,  425;    treatment  of,  426. 

Adenoids  as  portals  of  infection,  in  endo- 
carditis, 493;  in  acute  articular  rheu- 
matism, 402;  in  chorea,  701;  in  diph- 
theria, 295;  in  influenza,  311;  in  status 
lymphaticus,  545,  547. 

Adenoids,  removal  of,  as  protection 
against  acute  articular  rheumatism, 
406;  for  relief  of  asthma,  712;  as  pro- 
tection against  endocarditis,  493,  503 


indications  for,  427;  as  protection 
against  pericarditis,  512;  for  relief  of 
acute  rhinitis,  414;  for  relief  of 
chronic  rhinitis,  415 ;  for  relief  of  ton- 
sillar hypertrophy,  424;  as  protection 
against  tuberculosis,  395. 

Adrenalin,  use  of,  in  asthmatic  attacks, 
712;  in  epistaxis,  416;  in  hemophilia, 
539;  in  hemorrhage  in  new-born, 
83;  in  purpura  hemorrhagica,  537;  in 
splanchnic  paralysis  during  diphtheria, 
307. 

Agglutinins,  55. 

Albolin,  use  of,  in  scarlet  fever,  330. 

Albumin  water,  as  artificial  food,  128; 
in  infantile  atrophy,  201;  in  typhoid 
fever,  278. 

Albuminuria,  567;  cyclic,  568;  definition 
of,  567;  forms  of,  567;  in  influenza, 
312;  in  mumps,  359;  in  nephritis,  576; 
orthostatic,  568;  physiological,  567; 
postural,  568;  in  purpura  hemorrha- 
gica, 533;  in  purpura  rheumatica,  535; 
in  scarlet  fever,  322;  in  septic  infec- 
tion of  new-born,  78;  in  tonsillitis,  422; 
in  variola,  347;  in  whooping  cough, 
290. 

Albuminura,  toxic.    See  Nephritis,  toxic. 

Alcohol,  therapeutic  use  of,  in  broncho- 
pneumonia, 466;  in  acute  cardiac  dila- 
tation, 498;  in  lobar  pneumonia,  450; 
multiple  neuritis  due  to  undue  use  of, 
661;  in  toxic  nephritis,  574;  in  typhoid 
fever,  277. 

Alexins,  107. 

Alkalies,  therapeutic  use  of  in  acetonu- 
rla,  567;  in  acute  articular  rheuma- 
tism, 405;  in  enuresis,  602;  in  pica, 
705. 

Alkaline  diluents,  139. 

Alkaline  waters,  therapeutic  use  of,  in 
cystopyelitis,  586;  in  eczema,  722;  in 
acute  nephritis,  581;  in  chronic  ne- 
phritis, 583;  in  toxic  nephritis,  574; 
in  valvular  heart  disease  from  rheuma- 
tism, 504. 
Amaurotic  family  idiocy,  624. 

739 


740 


INDEX 


Ameba  coli,  178, 

Amyl  nitrite,  use  of,  in  epilepsy,  695. 

Amylase,  in  human  milk,  106. 

Anaphylaxis,  185. 

Anatomic  age  of  child,  19. 

Anderson  and  Frost,  on  the  extent  of 
paralysis  in  acute  anterior  poliomyeli- 
tis, 647, 

Anemia,  simple,  522;  due  to  acute  ar- 
ticular rheumatism,  404,  406;  blood 
picture  in,  523;  cause  of  chorea,  697; 
symptom  of  chorea,  700;  definition  of, 
522;  diagnosis  of,  523;  due  to  endocar- 
ditis, 490;  etiology  of,  522;  associated 
with  habit  spasm,  702;  associated  with 
hemophilia,  539 ;  associated  with  Hodg- 
kin  's  disease,  541 ;  due  to  malaria,  283 ; 
prognosis  of,  524;  due  to  purpura 
hemorrhagica,  533;  associated  with 
splenomegaly,  552;  associated  with 
sporadic  cretinism,  554;  symptomatol- 
ogy of,  523;  due  to  syphilis,  366;  asso- 
ciated with  toxic  nephritis,  572;  treat- 
ment of,  524;  associated  with  tubercu- 
losis of  lymph  nodes,  382;  associated 
with  valvular  heart  disease,  505. 

Anemia  of  infancy  and  childhood,  518, 
521, 

Anemia,  pernicious,  528;  blood  picture 
in,  528;  definition  of,  528;  diagnosis 
in,  529;  etiology  of,  528;  symptoma- 
tology of,  528;  treatment  of,  529. 

Anesthesia,  symptom  of  hysteria,  706. 

Anesthetics,  danger  from,  in  status 
lymphatieus,  550;  sudden  death  from, 
547. 

Angina,  gangrenous,  in  scarlet  fever, 
324;   ulcerative,  324. 

Angioneurotic  edema,  535. 

Anisocytosis,  516. 

Anopheles,  destruction  of,  284;  trans- 
mission of  malaria  by,  280. 

Anorexia  nervosa,  in  hysteria,  707. 

Antibodies,  syphilitic,  368. 

Antimeningitic  serum.    See  Serum. 

Antipyretics,  use  of,  in  bronchopneu- 
monia, 467;  in  fevers,  266;  in  lobar 
pneumonia,  451;  in  scarlet  fever,  329; 
in  typhoid  fever,  278. 

Antiserums,  therapeutic  use  of,  59. 

Antitoxin  of  diphtheria,  use  of,  in 
bronchopneumonia  complicating  diph- 
theria, 307;  use  of,  in  determining 
diphtheritic  character  of  pseudo-mem- 
branous rhinitis,  413 ;  use  of,  in  diag- 
nosis between  diphtheria  and  acute 
laryngitis,  432,  433;  use  of,  in  diagno- 
sis between  diphtheria  and  tonsillitis, 


420 ;  discovBTy  of,  302 ;  dose  of,  in  hos- 
pital practice,  303 ;  dose  of,  in  private 
practice,  304;  use  of,  with  intubation, 
304;  use  of,  in  membranous  laryngitis 
complicating  measles,  340;  method  of 
preparing,  302;  method  of  using,  303; 
mortality  of  diphtheria  reduced  by, 
300,  302;  use  of,  in  post-diphtheritic 
paralysis,  307;  prophylactic  use  of, 
3C2;  use  of,  in  scarlet  fever  compli- 
cating diphtheria,  330;  use  of,  in  sep- 
ticemia complicating  diphtheria,  307; 
skin  eruptions  following  use  of,  304; 
use  of,  in  stomatitis  gangrenosa,  153; 
use  of,  with  tracheotomy,  304. 

Antitoxin  of  tetanus,  59,  91. 

Anti-typhoid  inoculation,  276. 

Anuria,  560. 

Anus,  atresia  of,  233;  fissure  of,  235; 
malformation  of,  233;    spasm  of,  236. 

Aortic  regurgitation,  501. 

Aortic  stenosis,  501. 

Aphonia,  hysterical,  707. 

Appendicitis,  222 ;  blood  picture  in,  225 ; 
conditions  covered  by  term,  222;  diag- 
nosis of,  226;  etiology  of,  223;  indica- 
tions for  operation  in,  228;  mortality 
from,  227;  pathology  of,  223;  physical 
examination  in,  224;  prognosis  of, 
227;  symptomatology  of,  224;  treat- 
ment of,  227. 

Argyrol,  local  use  of,  in  diphtheria,  304; 
in  acute  follicular  tonsillitis,  423;  in 
gonorrheal  vulvovaginitis,  594;  in 
scarlet  fever,  330. 

Arnheim,  on  Eontgen-ray  picture  in  di- 
agnosis of  persistent  patulous  ductus 
arteriosus  Botalli,  488. 

Arnold  steam -sterilizer,  120. 

Arrhythmia,  506. 

Arsenic,  therapeutic  use  of,  in  asthma, 
713;  in  acute  cardiac  dilatation,  498; 
in  chorea,  700;  in  enuresis,  601;  in 
Hodgkin's  disease,  542;  in  malaria, 
286 ;  as  cause  of  multiple  neuritis,  661 ; 
in  pavor  nocturnus,  675;  in  pernicious 
anemia,  529;  pseudo-leukemia  unaf- 
fected by,  526;  in  pseudo-masturba- 
tion, 609;  in  simple  secondary  anemia, 
524;  toxic  nephritis  caused  by,  573, 
575;  in  valvular  heart  disease,  505. 

Arsenic,  Fowler's  solution  op.  See 
Fouler. 

Arthritis,  chronic  rheumatoid,  408. 

Arthritis,  chronic  villous,  407. 

Arthritis  deformans.  See  Chronic 
rheumatoid  arthritis. 

Arthritis,  infectious,  407. 


INDEX 


741 


Arthritis,  septic,  complicating  scarlet- 
fever,  324. 

Artificial  feeding  in  infancy,  addi- 
tional foods  in,  142;  albumin  water 
in,  128;  alkaline  diluents  in,  139; 
beef  juice  in,  129;  broths  in,  129; 
buttermilk  in,  122;  caloric  standard 
of  values  in,  130;  cane  sugar  in,  125; 
carbohydrates  in,  124,  135;  carbohy- 
drate diluents  in,  138;  casein  in,  135; 
cereal  decoctions  in,  126;  cleanliness 
essential  in,  133;  condensed  milk  in, 
126;  cow's  milk  in,  118;  determination 
of  accurate  percentages  in,  139;  dex- 
trinized  gruels  in,  126;  fat  in,  135; 
Finkelstein 's  albumin  milk  in,  123; 
food  formula}  in,  133 ;  fresh  air  essen- 
tial to  success  of,  134;  home  modifica- 
tion of  milk  in,  135;  ingredients  of, 
103;  malted  milk  in,  128;  maltose  in, 
125;  malt  soups  in,  124;  meat  prepa- 
rations in,  129 ;  necessity  for,  among 
poor,  115;  Nestle 's  food  in,  127;  over- 
feeding a  danger  in,  133 ;  pasteurized 
milk  in,  120;  peptonized  milk  in,  121; 
percentage  of  different  foodstuffs  in, 
134;  in  premature  infants,  67;  prin- 
ciples of,  132;  proprietary  foods  in, 
127;  regularity  essential  to  success  of, 
134;  rest  essential  to  success  of,  134; 
Botch  laboratory  method  of  modifica- 
tion in,  141;  skimmed  milk  in,  124; 
sterilized  milk  in,  119;  value  of  per- 
centage feeding  in,  129 ;  in  treatment 
of  whooping  cough,  292. 

Artificial  respiration,  72. 

AscARis  LUMBRicoiDES,  215;  treatment 
of,  216. 

Ascites,  232;  diagnosis  of,  232;  etiology 
of,  232;  treatment  of,  in  tumor  of  the 
kidney,  589;  treatment  of,  in  valvular 
heart  disease,  506. 

Asphyxia,  as  cause  of  idiocy,  623 ;  livida, 
70;  pallida,  70. 

Asphyxia  neonatorum,  69 ;  diagnosis  of, 
71;  etiology  of,  69;  prognosis  of,  71; 
prophylaxis  of,  71 ;  symptomatology  of, 
70;    treatment  of,   72. 

AsPiDiUM,  use  of,  in  tenia,  214. 

Aspiration,  in  pericarditis  with  effusion, 
513;   in  pleurisy  with  effusion,  479. 

Aspirin,  therapeutic  use  of,  in  endocar- 
ditis, 494 ;  in  fevers,  267 ;  in  influenza, 
314;  in  pleurisy,  478;  in  tonsillitis, 
422;  in  tuberculosis,  400. 

Astasia-abasia,  706. 

Asthma,  710;  definition  of,  710;  etiology 
of,  711;   prognosis  of,  712;   symptom- 


atology, 711;  thymic,  546;  treatment 
of,  during  attack,  712;  treatment  of, 
during  interval,  712. 

Ataxia,  hereditary,  657;  treatment  of, 
658. 

Atelectasis,  congenital,  73;  etiology 
of,  74;  symptomatology  of,  74;  treat- 
ment of,   75. 

Atrophy,  muscular,  in  facial  paralysis, 
665;  in  multiple  neuritis,  663;  in  acute 
^anterior  poliomyelitis,  648;  affecting 
the  voluntary  muscles,  666. 

Atropin,  therapeutic  use  of,  in  asthma, 
712;   in  ophthalmia  neonatorum,  97. 

Aura,  693. 

Auscultation,  value  of,  in  physical  ex- 
amination, 34. 

Autogenous  vaccines,  therapeutic  use 
of,  57. 

AuToiNFECTiONS,  a  cause  of  headache, 
709;  association  of,  with  toxic  nephri- 
tis, 573. 

AuTOToxiNs,  cause  of  eczema,  719;  cause 
of  headache,  709. 


Babinski  REFLEX,  in  epilepsy,  694;  in 
meningococcus  meningitis,  633;  method 
of  examination  for,  32 ;  in  muscular 
contracture  of  infantile  cerebral  palsy, 
613;  in  tuberculous  meningitis,  628. 

Bacillus:  B.  "blue,"  cause  of  enteric 
infection,  178;  B.  coli  communis,  see 
B.  colon;  B.  colon,  cause  of  cystopye- 
litis,  584;  cause  of  enuresis,  601;  cause 
of  fever  resembling  typhoid,  267;  cause 
of  simple  vulvovaginitis,  595;  B.  en- 
teriditis,  cause  of  fever  resembling  ty- 
phoid, 265,  267;  cause  of  meat-poison- 
ing, 267;  B.  gas,  see  B.  Welchii;  B. 
of  influenza,  308,  311;  cause  of  enteric 
infection,  178;  B.  Klebs-Loflaer,  295; 
B.  paratyphoid,  cause  of  fever  resem- 
bling typhoid,  265,  267;  cause  of 
meat-poisoning,  267;  B.  pertussis,  287; 
B.  Pfeiffer,  see  B.  of  influenza;  B. 
proteus,  as  cause  of  enteric  infection, 
178;  B.  pseudo-diphtheritic,  as  cause 
of  simple  vulvovaginitis,  595;  B. 
Shiga,  178;  B.  typhoid,  267;  B.  of  Vin- 
cent, 419;  B.  Welchii,  as  cause  of  en- 
teric infection,  178. 

Bacteria,  present  in  appendicitis,  223, 
224;  present  in  human  milk,  112;  pres- 
ent in  intestinal  canal  of  infant,  176, 
177;  entrance  of,  through  umbilical 
wound  in  sepsis  of  new-born,  263. 


742 


INDEX 


Bacterial  content,  in  cream,  133;  in 
milk,  118,  119. 

Babes  and  Zambolovici,  bacillus  isolated 
by,  found  in  gangrenous  stomatitis, 
152. 

Bacterial  substances.  See  Bacterwly- 
sins. 

Bacterial  vaccines,  therapeutic  use  of, 
55. 

Bacteriological  examination,  in  diag- 
nosis between  brain  abscess  and  menin- 
gitis, 618;  in  diagnosis  of  diphtheria, 
301;  in  prophylaxis  of  diphtheria, 
302;  in  diagnosis  between  diphtheria 
and  acute  laryngitis,  432,  433;  in  diag- 
nosis between  diphtheria  and  tonsillitis, 
420;  in  diagnosis  of  pleurisy  with  ef- 
fusion, 477 ;  in  diagnosis  of  acute  polio- 
myelitis, 649;  in  diagnosis  of  tubercu- 
lar meningitis,  629. 

Bacteriolysins,  55. 

Baginsky,  on  frequency  of  nephritis  aa 
complication  of  diphtheria,  300. 

Barlow,  on  acute  articular  rheumatism, 
402;  on  acute  articular  rheumatism  at- 
tacking the  hip  joint,  403;  on  infan- 
tile scurvy,  246. 

Basophiles,  517. 

Baths,  alkaline,  in  treatment  of  epil- 
epsy, 696;  in  treatment  of  purpura, 
536. 

Baths,  cold,  objections  to,  in  acute 
catarrhal  bronchitis,  442;  objections  to 
in  typhoid  fever,  277;  in  treatment  of 
fever  in  infancy,  266;  in  treatment  of 
fever  in  older  children,  267. 

Baths,  hot,  in  edema  of  larynx,  435;  in 
lobar  pneumonia,  451;  temperature  of, 
46;  therapeutic  value  of,  46. 

Baths,  Nauheim.    See  Nauheim. 

Baths,  salt,  in  treatment  of  rickets, 
245. 

Baths,  sponge,  in  bronchopneumonia, 
468;  in  cystopyelitis,  587;  in  fever  of 
infancy,  267;  in  lobar  pneumonia,  451; 
in  malaria,  286;  in  measles,  339;  in 
scarlet  fever,  329;  in  tonsillitis,  423; 
in  variola,  348;  temperature  of,  45; 
therapeutic  value  of,  45. 

Baths,  tepid,  in  fever  of  infancy,  267; 
in  influenza,  313;  in  typhoid  fever, 
277. 

Baths,  tub,  in  eclampsia,  682;  in  scarlet 
fever,  329;  in  tonsillitis,  423;  objec- 
tions to,  in  typhoid  fever,  277;  tem- 
perature of,  45 ;  therapeutic  value  of, 
45. 

Baths,  warm,  in  asphyxia  neonatorum. 


73;  in  bronchopneumonia,  468;  in 
acute  catarrhal  bronchitis,  442 ;  in 
chorea,  701;  in  acute  laryngitis,  433; 
in  meningococcus  meningitis,  638;  in 
multiple  neuritis,  663;  in  tetany,  689; 
in  toxic  nephritis,  574;  in  tuberculous 
bronchopneumonia,  401. 

Baumler,  on  results  of  vaccination,  350. 

Becamp,  discovery  of  amylase  by,  106. 

Beck,  on  pneumococcus  as  cause  of  pleu- 
risy in  child,  470. 

Bednar's  aphtha,  154. 

Bedsores  in  myelitis,  654,  656. 

Beef  juice,  value  of,  in  artificial  feed- 
ing,  129. 

Behrixg,  discovery  of  antitoxin  by,  302. 

Bell,  on  facial  paralysis,  665. 

Bell's  palsy.     See  Facial  paralysis. 

Belladonna,  therapeutic  use  of,  in 
asthma,  712;  in  bronchopneumonia, 
467;  in  acute  catarrhal  bronchitis,  441; 
in  cough  of  tuberculosis,  400;  in  enu- 
resis, 602;  in  epilepsy,  696;  in  in- 
fluenza, 313,  314;  in  lobar  pneumonia, 
453;  in  measles,  339;  in  pavor  noc- 
turnus,  675;  in  pseudo-masturbation, 
609;   in  whooping  cough,  293. 

Belladonna  ointment,  use  of,  in  mumps, 
360. 

Beneke,  on  increase  in  size  of  the  heart 
during  first  five  years  of  life,  484. 

Benoit,  on  digestive  ferments  present  in 
human  milk,  107. 

Benzoate  of  soda.  See  Sodium  hemo- 
ate. 

Benzoin,  compound  tincture  of,  use  of, 
by  inhalations,  in  acute  laryngitis,  433; 
in  acute  rhinitis,  414. 

Bernheim  and  Pospischill,  on  stomati- 
tis ulcerosa,  150. 

Bernouilli,  on  mortality  from  small-pox 
before  vaccination,  349. 

Betanaphthol,  in  chlorosis,  528;  in  per- 
nicious anemia,  529;  in  pseudo-leuke- 
mia, 526. 

Bicarbonate  of  soda.  See  Sodium  bi- 
carbonate. 

Bicarbonate  op  potash.  See  Potassium 
bicarbonate. 

Bile  ducts,  occlusion  of,  in  new-born, 
93. 

Birth  injuries,  97;  birth  palsies,  98; 
cephalhematoma,  97;  facial  paralysis, 
98;  hematoma  of  the  sterno-cleido-mas- 
toid  muscle,  98;  upper-arm  paralysis, 
99. 

Birth  palsies,  98. 

Bismuth  subnitrate,  external  use  of.  in 


INDEX 


743 


erythema  multiforme,  730 ;  in  syphilitic 
ulcerations,  373. 

Bismuth  subnitrate,  internal  use  of,  in 
diarrhea  of  tuberculosis,  400,  401;  in 
diarrhea  of  typhoid  fever,  278;  ia  en- 
teric infection,  195. 

Blackader,  on  prognosis  in  typhoid  fe- 
ver, 275;  on  relapses  in  typhoid  fever, 
274. 

"Black  measles/'  335. 

Blaud's  pills,  therapeutic  use  of,  in 
chlorosis,  528;   in  purpura,  536. 

"Bleeders,"  537. 

Blisters,  in  treatment  of  facial  paraly- 
sis, 666;  in  treatment  of  hysteria,  708; 
contraindicated  in  treatment  of  acute 
pericarditis,  512. 

Blood,  color  index  of,  516;  diseases  of, 
515;  diagnostic  importance  of,  37; 
peculiarities  of,  in  infancy  and  child- 
hood, 518;  physiology  of,  515;  plate- 
lets of,  517;  red  corpuscles  of,  515; 
white  corpuscles  of,  516. 

Blood,  character  of,  in  acute  articular 
rheumatism,  404;  in  appendicitis,  225; 
in  chlorosis,  527;  in  chorea,  700;  in 
congenital  heart  disease,  486;  in  diph- 
theria, 297;  in  Hodgkin's  disease,  541; 
in  influenza,  310;  in  leukemia,  530;  in 
lobar  pneumonia,  447;  in  malaria,  284; 
in  measles,  336;  in  meningitis,  634;  in 
pernicious  anemia,  528;  in  poliomyeli- 
tis, 649;  in  pseudo-leukemia,  525;  in 
purpura,  532;  in  recurrent  vomiting, 
254;  in  rickets,  242;  in  rubella,  343; 
in  scarlet  fever,  322 ;  in  simple  second- 
ary anemia,  523;  in  status  lymphati- 
cus,  547;  in  syphilis,  366,  368;  in  ty- 
phoid fever,  273;  in  varicella,  356; 
in  variola,  347;  in  whooping  cough, 
289. 

Blood  corpuscles,  red,  function  of,  515 ; 
number  of,  515;  origin  of,  518;  patho- 
logical changes  in,  515;  reduction  of, 
in  chlorosis,  526,  527;  reduction  of,  in 
Hodgkin's  disease,  541;  reduction  of, 
in  leukemia,  530;  reduction  of,  in  per- 
nicious anemia,  528;  reduction  of,  in 
simple  secondary  anemia,  523;  varieties 
of,  515. 

Blood  corpuscles,  white,  number  of, 
516;  origin  of,  516;  pathological 
changes  in,  517;  varieties  of,  516. 

Blood,  diseases  of,  515;  chlorosis,  526; 
hemophilia,  537;  leukemia,  530;  perni- 
cious anemia,  528;  pseudo-leukemia, 
524;  purpura,  531;  simple  secondary 
anemia,  522. 


Blumeneeich,  on  area  of  dulness  pro- 
duced by  the  thymus  gland,  547. 

BoGGS,  on  changes  in  area  of  thymic  dul- 
ness, 547. 

BoKAY,  on  frequency  of  retropharyngeal 
abscess  in  first  year  of  life,  428. 

Bones,  changes  in,  due  to  syphilis,  365, 
367;  changes  in,  due  to  tuberculosis, 
373,  381,  391;  deformities  of,  due  to 
rickets,  240;  treatment  of  tuberculosis 
of,  401. 

Bony  framework,  growth  and  develop- 
ment of,  19. 

Booker,  on  proteus  vulgaris  as  a  cause 
of  enteric  infection,  178;  on  strepto- 
coccus enteriditis  as  a  cause  of  enteric 
infection,  178. 

BoRACic  acid,  as  irrigating  solution  in 
vulvovaginitis,   594. 

BoRDET  and  Genow,  isolation  of  "bacil- 
lus pertussis"  by,  287. 

Bothriocephalus  latus,  212. 

BovAiRD,  on  primary  intestinal  tubercu- 
losis, 380. 

Bowditch,  on  measurements  of  growth  in 
children,  17. 

Boyd,  on  weight  of  brain  in  early  life,  23. 

Bradycardia,  507. 

Brain  abscess,  617;  course  of,  618;  di- 
agnosis of,  618;  duration  of,  618;  eti- 
ology of,  617;  situation  of,  617;  symp- 
tomatology of,  618;  treatment  of,  618. 

Brain,  diseases  of,  610;  abscess,  617; 
amaurotic  family  idiocy,  624;  encepha- 
locele,  621;  hydrencephalocele,  622;  hy- 
drocephalus, acute,  618;  hydrocephalus, 
chronic,  618;  idiocy,  622;  meningocele, 
621;  microcephalic  idiocy,  625;  Mon- 
golian idiocy,  624;  tumors,  616. 

Brain  tumors,  616;  diagnosis  of,  617; 
general  symptoms  of,  616;  local  symp- 
toms of,  617;  nature  of,  616;  position 
of,  616;  treatment  of,  617. 

Brandy,  therapeutic  use  of,  in  broncho- 
pneumonia, 466;  in  acute  cardiac  dila- 
tation, 498;  in  diphtheria,  307;  in 
lobar  pneumonia,  450;  in  scarlet  fever, 
329;   in  typhoid  fever,  277. 

Branchial  cysts,  158. 

Breast  feeding,  112;  importance  of,  to 
premature  infant,  67;  mixture  of  other 
food  with,  114;  normal  method  of, 
112;  weaning  from,  116;  wet  nurse  for, 
117. 

Breast  milk.    See  Milk,  human. 

Breasts,  swelling  and  tenderness  of,  as 
complication  of  mumps,  359. 

Beeathino  exercises,  53. 


744 


INDEX 


Breck,  feeding  tube  devised  by,  68. 

Brewer's  method  of  drainage  in  em- 
pyema, 480. 

Bright 's  disease,  as  complication  of 
bronchopneumonia,  460;  as  complica- 
tion of  measles,  336.  See  also  Acute 
nephritis. 

Broadbent,  on  irregular  fever  resisting 
quiniu  suggesting  acute  endocarditis, 
490;  on  exaggeration  of  diastolic  shock 
in  chronic  pericarditis,  514. 

Bromid  of  potash,  use  of,  in  asthma, 
712 ;  in  acute  catarrhal  bronchitis,  441 ; 
in  bronchopneumonia,  467;  in  chorea, 
701;  in  diphtheria,  306;  in  enuresis, 
603;  in  epilepsy,  695;  in  influenza, 
314;  in  acute  laryngitis,  432;  in  lobar 
pneumonia,  453 ;  in  measles,  339 ;  in 
acute  nephritis,  581;  in  pavor  noctur- 
nus,  675;  in  pseudo-masturbation,  609; 
in  typhoid  fever,  278;  in  variola,  348; 
in  urticaria,  727;  in  whooping  cough, 
294. 

Bromid  of  soda,  use  of,  in  influenza, 
314;  in  measles,  339;  in  pavor  noc- 
turnus,  675;  in  acute  pericarditis, 
513;   in  poliomyelitis,  651. 

Bromids,  use  of,  in  cough  of  tuberculosis, 
400;  in  acute  endocarditis,  -493;  in 
functional  heart  disorders,  509;  in 
headache,  710;  in  hysteria,  708;  in  in- 
somnia, 677;  in  meningococcic  menin- 
gitis, 638;  in  acute  nephritis,  581;  in 
multiple  neuritis,  664;  in  nystagmus 
and  head-nodding,  691;  in  purulent 
meningitis,  641;  in  tetany,  689;  in 
thyroid  intoxication,  558. 

Bronchi,  foreign  bodies  in,  435. 

Bronchitis,  acute  catarrhal,  438;  age  as 
predisposing  factor,  439;  complications 
of,  440;  definition  of,  438;  diagnosis 
of,  440;  duration  of,  440;  etiology  of, 
438 ;  fever  in,  439 ;  microorganisms 
present  in,  438;  mortality  from,  in 
young  children,  2;  pathology  of,  439; 
physical  signs  of,  440;  prognosis  of, 
440;  prophylaxis  in,  441;  sources  of 
infection  in,  438;  symptomatology  of 
439;   treatment  of,  441. 

Bronchitis,  afebrile  asthmatic,  440. 

Bronchitis,  chronic,  442. 

Bronchitis,  membranous,  442. 

Bronchopneumonia,  454;  abortive  type 
of,  461 ;  as  complication  of  acute  ca- 
tarrhal bronchitis,  438,  440;  as  ot^r^ 
plication  of  congenital  atelectasis,  74; 
as  complication  of  diphtheria,  300, 
307;  as  complication  of  influenza,  312  j 


as  complication  of  measles,  336,  338; 
as  complication  of  whooping  cough, 
455;  complications  of,  462;  counterir- 
ritation  in  treatment  of,  468 ;  degluti- 
tion type  of,  462;  diagnosis  of,  463; 
dietetic  treatment  of,  465 ;  etiology  of, 
454;  gastroenteritis  followed  by,  462; 
hygienic  treatment  of,  465 ;  medical 
treatment  of,  466;  microorganisms 
present  in,  454,  455;  mortality  from, 
464;  in  new-born,  461;  pathology  of, 
455;  physical  signs  in,  460;  poultices 
in  treatment  of,  468;  predisposing 
causes  of,  454;  prognosis  of,  464;  pro- 
phylaxis of,  464;  pulse  rate  in,  457; 
sources  of  infection  in,  455 ;  sputum 
findings  in,  460;  symptomatology  cf, 
456;  temperature  curve  in,  457,  458; 
treatment  of,  464;  treatment  of  during 
convalescence,  469 ;  tuberculous  form 
of,  386,  462;  types  of,  461;  urine  find- 
ings in,  459. 

Broths,  use  of,  in  diet  of  infancy,  129, 
142;  in  diet  of  typhoid  fever,  277. 

Brudzinski,  on  proteus  vulgaris  in  causa- 
tion of  enteric  infection,  178. 

Bryant's  method  of  drainage  in  em- 
pyema, 480. 

BuDiN,  on  the  influence  of  demand  on 
supply  in  breast  milk,  113. 

Buhl's  disease.  See  Acute  fatty  degen- 
eration of  new-horn. 

Burk,  measurements  of  growth  in  chil- 
dren by,  17. 

Buttermilk,  use  of,  in  artificial  feeding 
of  infants,  122;  in  chronic  gastritis, 
172;  in  enteric  infection,  194;  in  in- 
fantile atrophy,  201;  in  typhoid  fever, 
277. 


Caffein  citrate,  for  relief  of  headache, 
710. 

Caffein  sodium  benzoate,  therapeutic 
use  of,  in  acute  cardiac  dilatation, 
498;  in  diphtheria,  307;  in  lobar  pneu- 
monia, 453;  in  poliomyelitis,  651;  in 
scarlet  fever,  330. 

Caffein  sodium  salicylate,  hypodermic 
use  of,  in  splanchnic  paralysis  of  diph- 
theria, 307. 

Calcium,  presence  of,  in  milk,  104; 
uses   of,   to   body,   105. 

Calcium  salts,  therapeutic  use  of,  in 
furunculosis,  729;  in  hemophilia,  540; 
in  purpura,  536;  in  sporadic  cretinism, 
556;  in  tetany,  689. 


INDEX 


745 


Calomel,  therapeutic  use  of,  in  acido- 
miria,  567;  in  acute  articular  rheuma- 
tism, 405;  in  combination  with  san- 
tonin for  relief  of  ascaris  lumbricoides, 
216;  in  chorea,  700;  in  chronic  con- 
stipation, 207;  in  enteric  infection, 
193;  in  erythema  multiforme,  730;  in 
acute  gastric  indigestion,  160;  in  acute 
gastritis,  162;  in  gastroduodenitis, 
165;  in  headache,  710;  in  influenza, 
313;  in  intestinal  indigestion,  187;  in 
lobar  pneumonia,  452 ;  in  malaria,  266 ; 
in  multiple  neuritis,  663;  in  combina- 
tion with  santonin  for  relief  of  oxyuris 
vermicularis,  218;  in  poliomyelitis, 
651;  in  purpura,  536;  in  recurrent 
vomiting,  258;  in  scarlet  fever,  329; 
in  syphilis  externally,  373;  in  syphilis 
internally,  370,  371;  in  tetany,  689; 
in  tonsillitis,  422 ;  in  typhoid  fever,  277. 
Calomel,    use    of,    by    sublimation,    in 

laryngeal  diphtheria,  304. 
Caloric  standard  in  artificial  febujinq 

of  infants,  130. 
Camerer  and  Soldner,  on  composition  of 

colostrum,  108. 
Camphor,    therapeutic   use    of,    in   acute 

cardiac  dilatation,  498. 
Camphorated  oil,  therapeutic  use  of,  as 
counterirritant     in    bronchopneumonia, 
468;  to  bring  out  eruption  in  measles, 
340. 
Cancrum  oris.     See  Stomatitis  gangre- 
nosa. 
Cane  sugar,  use  of,  in  artificial  feeding 

of  infants,  125. 
Cannabis  indica,  therapeutic  use  of,  in 

epilepsy,  696. 
Cantharides,  as  cause  of  hematuria, 
563;  as  cause  of  toxic  nephritis,  573, 
575. 
Carbohydrate  diluents,  138. 
Carbohydrates,  103,  124;  acid  intoxica- 
tion due  to  deficient  absorption  of,  103 ; 
addition  of,  to  skimmed  milk,  124;  use 
of,  in  artificial  food,  135;  indigestion 
due  to  deficiency  of,  104;  indigestion 
due  to  excess  of,  104;  food  value  of, 
103,  138;  food  value  of,  in  acetonuria, 
565;  food  value  of,  in  diabetes,  250, 
251;  food  value  of,  in  intestinal  dis- 
orders, 178;  proportion  of,  in  butter- 
milk, 122,  123;  proportion  of,  in  Fin- 
kelstein's  albumin  milk,  123;  propor- 
tion of,  in  milk,  103;  proportion  of,  in 
modified  milk  mixture,  124;  skimmed 
milk  in  relation  to,  124;  symptoms  of 
over-feeding  with,  184,  186. 


Carbolic  acid  ointment,  use  of,  in  ery- 
thema multiforme,  730;  in  measles. 
339. 

Carbonate  of  potash.  See  Potqssium 
carbonate. 

Cardiac  dilatation,  acute,  496;  diagno- 
sis of,  496;  diagnosis  between  peri- 
carditis and,  511;  in  diphtheria,  296, 
297;  etiology  of,  496;  in  influenza,  312, 
314;  prognosis  of,  496;  prophylaxis  of, 
497;  treatment  of,  498;  in  whooping 
cough,  290. 

Cardiac  diseases.    See  under  Heart. 

Cardiac  compensation,  acute  cardiac 
dilatation  due  to  failure  of,  496 ;  in  mi- 
tral regurgitation,  499;  in  mitral  steno- 
sis, 500;  failure  of,  in  chronic  valvu- 
lar heart  disease,  502;  treatment  of, 
505;  tricuspid  regurgitation  due  to 
failure  of,  502. 

Cardiac  murmurs.    See  Murmurs. 

Cardiac  paralysis,  in  diphtheria,  299; 
in  multiple  neuritis,  663. 

Caries  of  spine.    See  Pott's  disease. 

"Carriers:"  of  diphtheria,  295;  of  tu- 
berculosis, 373;  of  typhoid  fever,  267, 
268. 

Cascara,  therapeutic  use  of,  in  con- 
stipation, 207;  in  measles,  340;  in 
acute  nephritis,  579;  in  scarlet  fever, 
329. 

Casein,  action  of  alkalies  on,  139;  com- 
position of,  102;  excess  of,  injurious, 
135;  inability  to  digest,  186;  propor- 
tion of,  in  buttermilk,  123;  proportion 
of,  in  milk,  102. 

Castor-oil,  therapeutic  use  of,  in  acute 
catarrhal  bronchitis,  442;  in  broncho- 
pneumonia, 466;  in  chorea,  700;  in 
eclampsia,  682;  in  enteric  infection, 
196;  in  erythema  multiforme,  730;  in 
fever,  266;  in  headache,  710;  in  He- 
noch's purpura,  537;  in  acute  intes- 
tinal indigestion,  187,  188;  in  lobar 
pneumonia,  452;  in  measles,  340;  in 
multiple  neuritis,  663;  in  poliomyelitis, 
651;  in  pseudo-leukemia,  526;  in  sto- 
matitis catarrhalis,  147;  in  stomatitis 
aphthosa,  148;  in  stomatitis  myeosa, 
150;  in  tonsillitis,  422;  in  typhoid  fe- 
ver, 277;  in  urticaria,  727. 

Castor-oil,  use  of,  contraindicated,  in 
constipation  of  infants,  204,  206;  in 
acute  gastric  indigestion,  160;  in  acute 
gastritis,  162. 
Catarrh,  acute  nasal.  See  Bhinitis, 
acute. 


746 


INDEX 


Catarrhal  jaundice.  See  Gastroduo- 
denitis. 

Cathartics,  therapeutic  use  of,  in  cho- 
rea, 700;  in  eclampsia,  683;  in  ery- 
thema multiforme,  730;  in  headache, 
709;  in  lobar  pneumonia,  452;  in 
measles,  340;  in  acute  nephritis,  578; 
in  toxic  nephritis,  574;  in  pavor  noc- 
turnus,  675;  in  purpura,  536;  in  urti- 
caria, 727. 

Catheter,  form  of,  for  use  in  gonorrheal 
vulvovaginitis,  594;  importance  of 
sterilizing,  in  myelitis,  656. 

Catheterization,  indications  for,  in  in- 
fant, 559;  necessity  for,  in  myelitis, 
656. 

Cellulitis,  as  complication  of  vaccinia, 
353,  354. 

Cephalhematoma,  in  new-born,  97. 

Cereal  decoctions,  in  artificial  feeding 
of  infants,  126,  135;  as  medium  for 
quinin,  285;  in  diet  of  typhoid  fever, 
277,  278. 

Cerebral  croup.  See  Laryngismus 
stridulus. 

Cerebral  hemorrhage,  as  cause  of  epi- 
lepsy, 692 ;  as  complication  of  Henoch 's 
purpura,  535. 

Cerebrospinal  fluid,  diagnostic  value 
of,  37;  in  diagnosis  between  brain  ab- 
scess and  meningitis,  618;  in  meningo- 
coccus meningitis,  634;  in  poliomyeli- 
tis, 649;  in  purulent  meningitis,  639; 
in  tuberculous  meningitis,  629. 

Cerebrospinal  meningitis.  See  Menin- 
gitis, meningococcus. 

Cestodes,  intestinal,  211;  ascaris  lum- 
bricoides,  215;  bothriocephalus  latus, 
212;  hymenolepis  nana,  212;  oxyuris 
vermicularis,  217;  tenia  elliptica,  213; 
tenia  saginata,  211 ;  tenia  solium,  211. 

Chapin,  on  albuminuria  in  pulmonary 
disease,  572;  on  education  of  infant 
stomach,  122;  on  gastrointestinal  dis- 
orders, as  cause  of  toxic  nephritis,  572; 
measurements  of  growth  in  children  by, 
17. 

Chapin 's  infant  urinal,  559. 

Chart,  showing  temperature  curve,  in 
bronchopneumonia  (mild),  459;  in 
bronchopneumonia  (severe),  460;  in 
congenital  malaria,  282;  in  empyema, 
474;  in  empyema,  following  pleurisy, 
473;  in  gastroenteric  infection  (mild), 
189;  in  gastroenteric  infection  (se- 
vere), 190;  in  laryngeal  diphtheria 
treated  with  antitoxin  and  intubation, 
298;  in  lobar  pneumonia  in  child  two 


years  old,  445;  in  lobar  pneumonia  in 
child  four  years  old,  446;  in  lobar 
pneumonia  in  child  ten  years  old,  447; 
in  measles  (uncomplicated),  336;  in 
measles,  complicated  with  broncho- 
pneumonia, 337,  338;  in  meningococcic 
meningitis  in  child  six  years  old,  634; 
in  pharyngeal  diphtheria  treated  with 
antitoxin,  297;  in  anterior  polio- 
myelitis of  bulbar  type,  446;  in  puru- 
lent meningitis  in  child  ten  years  old, 
640;  in  scarlet  fever  in  child  six  years 
old,  320;  in  scarlet  fever  in  child 
twelve  years  old,  319;  in  tuberculous 
meningitis  in  child  twenty  months  old, 
629;  in  typhoid  fever  in  child  two  and 
a  half  years  old,  270;  in  typhoid  fever 
in  child  six  years  old,  271 ;  in  typhoid 
fever  in  child  ten  years  old,  272;  in 
typhoid  fever  relapse  in  child  three 
years  old,  274. 

Chart,  showing,  blood  changes  in  derma- 
titis exfoliativa  in  new-born,  79 ;  blood 
changes  in  purpura  hemorrhagica,  534; 
mortality  in  diphtheria  when  treated 
with  antitoxin,  303 ;  mortality  by  age 
in  scarlet  fever,  326;  ratio  of  increase 
in  weight  in  dull,  mediocre,  and  pre- 
cocious children,  16;  weight  in  artifi- 
cially fed  infants,  136;  weight  in 
breast-fed  infants,  114. 

Cheadle,  on  acute  articular  rheumatism, 
402,  489 ;  on  relation  between  chorea 
and  endocarditis,  697. 

Chest,  palpation  of,  30. 

Cheyne-Stokes  respiration,  in  menin- 
gococcic meningitis,  633;  in  tubercu- 
lous meningitis,  628. 

Chittenden,  analysis  by,  of  Nestle 'a 
food,  127. 

Chicken-pox.    See  Varicella. 

Child  crowing.  See  Laryngismus  stridu- 
lus. 

Childhood,  excessive  nerve  activity  in,  6; 
heat-dissipating  mechanism  in,  26; 
heat-regulating  mechanism  in,  25;  in- 
hibitory function  undeveloped  in,  24; 
irritability  of  nervous  system  in,  24; 
mortality  in,  1,  2;  muscular  develop- 
ment in,  20;  nervous  system  in,  23; 
peculiarities  of  blood  in,  518;  rest 
essential  to  health  in,  11;  sleep  in,  13; 
temperature  in,  easily  affected,  26; 
weight  important  in,   13,  16. 

Chloral,  therapeutic  use  of,  in  asthma, 
712;  in  chorea,  701;  in  cough  of 
measles,  339 ;  in  cough  of  tuberculosis, 
400;    in   eclampsia,    683;    in    epilepsy, 


mDEX 


747 


696;  in  meningococcic  meningitis,  638; 
in  acute  nephritis,  581;  in  purulent 
meningitis,  641;  in  tetanus  neonato- 
rum, 92;  in  tetany,  689;  in  variola, 
348;  in  whooping  cough,  294. 

Chloranemia,  545,  547;  treatment  of, 
550. 

Chlorate  of  potash.  See  Potassium 
chlorate. 

Chlorid  of  soda.     See  Sodium  chlorid. 

Chloroform,  inhalation  of,  in  asthma, 
712;  in  chorea,  701;  in  diagnosis 
between  laryngeal  diphtheria  and 
spasmodic  catarrhal  croup,  302;  in 
eclampsia,  682;  in  epilepsy,  695;  in 
laryngismus  stridulus,  686;  in  acute 
laryngitis,  433;  in  acute  nephritis,  581; 
danger  from,  in  status  lymphaticus, 
547. 

Chlorosis,  526;  blood  changes  in,  527; 
color  index  of,  526;  definition  of,  526; 
diagnosis  of,  527;  diet  in,  527;  drugs 
in  treatment  of,  527 ;  etiology  of,  527 ; 
predisposing  causes  of,  527;  prognosis 
of,  527;  symptomatology  of,  527; 
treatment  of,  527. 

Cholera  infantum,  192;  heat  as  cause 
of,  262 ;  hypodermic  medication  in,  196. 

Chorea,  696;  in  acute  articular  rheuma- 
tism, 404;  cardiac  murmurs  in,  700; 
definition  of,  696;  diet  in,  700;  drugs 
in  treatment  of,  700;  duration  of,  698; 
endocarditis  associated  with,  489;  eti- 
ology of,  697;  exciting  causes  of,  697; 
general  treatment  of,  700;  hygienic 
measures  in,  701;  medical  treatment 
of,  700;  predisposing  causes  of,  697; 
prognosis  of,  698;  symptomatology  of, 
698;  treatment  of,  700;  urine  findings 
in,  700. 

Chorea  minor.    See  Chorea. 

Chrysarobin,  therapeutic  use  of,  in  tinea 
tonsurans,  734. 

Chvostek,  on  causation  of  tetany,  687. 

Chvostek's  symptom,  688,  689. 

Circumcision,  for  paraphimosis,  597;  for 
phimosis,  596,  601. 

Citbate  op  potash.  See  Potassium  ci- 
trate. 

Clark,  Andrew,  on  constipation  in  rela- 
tion to  chorea,  527. 

Cleft  palate,  156. 

Climate,  influence  of,  in  causation,  of 
acute  articular  rheumatism,  402;  of  in- 
fluenza, 308;  of  poliomyelitis,  643. 

Climate,  influence  of,  in  treatment,  of 
asthma,  713;  of  chorea,  701;  of  endo- 
carditis in  rheumatic  subjects,  493;  of 


hemoglobinuria,  565;  of  heart  disease, 
due  to  rheumatism,  503;  of  chronic  in- 
fluenza, 314;  of  chronic  nephritis,  583; 
of  recurrent  vomiting,  257;  of  tubercu- 
losis, 396,  401. 

Clouston,  on  difference  between  brain  in 
childhood  and  maturity,  23. 

Clubbed  fingers,  in  congenital  heart 
disease,  486. 

Coal-oil,  therapeutic  use  of,  in  pediculo- 
sis capillitii,  737. 

Coal-tabs,  use  of,  contraindicated,  in 
chronic  headache,  710;  in  lobar  pneu- 
monia, 451;  in  thyroid  intoxication, 
558;   in  typhoid  fever,  278. 

Codein,  therapeutic  use  of,  in  cough  of 
influenza,  314;  in  cough  of  measles, 
339;  in  lobar  pneumonia,  453;  in  pleu- 
risy, 478;  in  paroxysms  of  whooping 
cough,  294;  in  tumor  of  kidney,  589; 
in  variola,  348. 

Cod-liver  oil,  therapeutic  use  of,  in  acute 
articular  rheumatism,  406;  in  asthma, 
713;  in  chronic  bronchitis,  442;  in 
chorea,  701;  in  constipation,  207;  in 
convalescence  from  bronchopneumonia, 
469 ;  in  convalescence  from  influenza, 
315;  in  convalescence  from  acute  laryn- 
gitis, 433;  in  convalescence  from  lobar 
pneumonia,  453;  in  enuresis,  601;  in 
facial  paralysis,  666;  in  laryngismus 
stridulus,  686;  in  multiple  neuritis, 
664;  in  nystagmus  and  head-nodding, 
691;  in  pavor  nocturnus,  675;  in 
pseudo-masturbation,  609 ;  in  rickets, 
244;  in  scurvy,  250;  in  simple  second- 
ary anemia,  524;  in  status  lymphati- 
cus, 550;  in  tetany,  689;  in  tuberculo- 
sis, 399. 

CoiT,  on  examination  of  milk,  118. 

Collabgolum,  therapeutic  use  of,  in  scar- 
let fever,  330;  in  ulcerative  endocardi- 
tis, 494;   method  for,  331. 

CoLLABGUM,  suppositorics  of,  52. 

COLLES'   LAW,   361. 

Collodion,  flexible,  use  of,  in  adenitis, 
544;  in  adenitis  in  scarlet  fever,  331; 
in  tinea  tonsurans,  735. 

Cold,  exposube  to,  a  cause  of  hemoglo- 
binuria, 565 ;  of  nephritis,  575. 

Cold  baths.    See  Baths. 

Cold  compress.     See  Compress. 

Cold  packs.    See  Packs. 

CoLi  vaccine,  therapeutic  use  of,  59. 

Colon  bacillus,  as  cause,  of  cystopyeli- 
tis,  584;  of  enuresis,  601;  of  fever  re- 
sembling typhoid,  267;  of  simple  vul- 
vovaginitis, 595. 


748 


INDEX 


Colon,  congenital  dilatation  op,  208; 
etiology  of,  208 ;  prognosis  of,  209 ; 
symptomatology  of,  209;  treatment  of, 
209. 

Color  index  op  blood,  in  chlorosis,  526; 
in  pernicious  anemia,  528;  in  simple 
anemia,  523;  significance  of,  516. 

Colostrum,  107. 

Coma,  in  aeetonuria,  566;  in  meningococ- 
cic  meningitis,  633;  in  acute  nephritis, 
576;  in  purulent  meningitis,  639;  in 
tuberculous  meningitis,  628. 

CoMBY,  on  antitoxin  in  post-diphtheritic 
paralysis,  307;  on  congenital  mumps, 
358;  on  relapses  in  typhoid  fever,  274; 
on  respiratory  manifestations  in  lithe- 
mia,  711. 

Compensation,  cardiac.     See  Cardiac. 

Compound  licorice  powder,  579. 

Compress,  cold,  46;  hot,  46. 

Condensed  milk.    See  Milk. 

Condylomata,  in  hereditary  syphilis, 
364. 

Congenital  hypertrophy  op  the  py- 
lorus, 166;  diagnosis  of,  168;  etiology 
of,  166;  pathology  of,  166;  prognosis 
of,  169;  symptomatology  of,  167; 
treatment  of,  169. 

Congenital  ichthyosis,  730;  treatment 
of,  731. 

Conjunctival  tuberculin  test.  See 
Tuberculin. 

Conjunctivitis,  in  gonorrheal  vaginitis, 
593;  in  influenza,  312;  in  measles,  338; 
in  acute  rhinitis,  413. 

Connors,  J.  F.,  on  food  percentages,  139. 

Consanguinity,  relation  to,  in  parents 
to  congenital  idiocy,  623. 

Constipation,  in  appendicitis,  224;  in 
congenital  dilatation  of  the  colon,  208; 
in  congenital  hypertrophy  of  pylorus, 
167;  in  enteric  infection,  191;  associ- 
ated with  enuresis,  603;  due  to  Finkel- 
stein's  albumin  milk,  124;  in  chronic 
gastritis,  171;  in  gastroduodenitis, 
165;  in  icterus  neonatorum,  94;  in  in- 
testinal indigestion  of  infants,  198;  in 
intestinal  indigestion  of  older  children, 
202;  in  malaria,  286;  in  peritonitis, 
231 ;  in  recurrent  vomiting,  253 ;  rec- 
tal suppositories  in  treatment  of,  206; 
in  sporadic  cretinism,  554;  due  to  ster- 
ilized milk,  120;  in  typhoid  fever,  272; 
treatment  of,  in  typhoid  fever,  278. 

Constipation,  chronic,  204;  diagnosis 
of,  205;  dietetic  causes  of,  204;  die- 
tetic treatment  of,  in  first  year,  206; 
dietetic  treatment  of,  in  second  year, 


207;  etiology  of,  204;  medical  treat- 
ment of,  207;  symptomatology  of,  205; 
treatment  of,  in  infancy,  206;  treat- 
ment of,  in  older  children,  207. 

Convulsions,  in  cystopyelitis,  585;  in 
epilepsy,  694;  in  hemiplegia,  612;  in 
malaria,  284;  in  uremia,  due  to  acute 
nephritis,  576. 

CoRYZA,  acute,  see  Acute  rhinitis;  danger 
from,  in  infancy,  6;  in  influenza,  310; 
treatment  of,  in  influenza,  313;  recur- 
rent, 258;  syphilitic,  362,  363. 

Cough,  character  of,  in  bronchopneumo- 
nia, 457;  in  acute  catarrhal  bronchitis, 
439;  in  influenza,  311;  in  laryngeal 
diphtheria,  298;  in  acute  laryngitis, 
430;  in  lobar  pneumonia,  447;  in 
measles,  334 ;  in  pleurisy,  473 ;  in  retro- 
pharyngeal abscess,  428;  in  acute  rhi- 
nitis, 413;  in  enlarged  thymus,  546;  in 
tuberculosis,  400;  in  whooping  cough, 
289. 

Cough  syrups,  contraindicated,  in  acute 
bronchitis,  441;  in  bronchopneumonia, 
467. 

Councilman,  on  "  cytorrhyctes  variolae, " 
345;  on  vesicular  fluid  in  chicken-pox, 
356. 

Counterirritation,  use  of,  in  broncho- 
pneumonia, 468;  in  facial  paralysis, 
666;  in  lobar  pneumonia,  451;  objec- 
tions to,  in  acute  pericarditis,  512;  in 
chronic  pericarditis,  513;  in  pleurisy, 
478. 

CouTTS,  on  night-terror,  673,  674. 

Cowan,  on  mortality  from  small-pox  be- 
fore vaccination,  350. 

Cow's  milk.    See  Milk. 

Cow-pox.    See  Vaccinia. 

Crandall,  on  congenital  malaria,  281 ;  on 
infantile  scurvy,  246;  on  vaccination, 
349. 

Cream,  as  source  of  fat  in  artiflcial  feed- 
ing, 135;  use  of,  in  constipation,  206; 
percentage  of,  in  modified  milk,  137. 

Cream  mixtures,  furnished  by  Walker- 
Gordon  Laboratories,  141;  objections 
to  use  of,  in  constipation,  206;  injury 
due  to  excess  of,  186. 

Creosote,  therapeutic  use  of,  in  chronic 
bronchitis,  442;  in  convalescence  from 
bronchopneumonia,  469 ;  in  lobar  pneu- 
monia, 452;  in  tuberculosis,  398;  by  in- 
halation in  measles  with  septic  com- 
plications, 340. 

Cresolin,  inhalations  of,  in  rhinitis,  414; 
in  whooping  cough,  293. 

Cretinism,  endemic,  553. 


INDEX 


749 


Ceetinism,  sporadic,  552;  definition  of, 
553;  diagnosis  of,  from  Mongolian 
idiocy,  554;  diagnosis  of,  from  thyroid 
insufficiency,  555;  etiology  of,  553; 
prognosis  of,  555;  treatment  of,  555; 
varieties  of,  552. 

Crocker,  on  treatment  of  tinea  tonsurans, 
735. 

Croup,  cerebral,  see  Laryngismus  stridu- 
lus; false,  see  Acute  laryngitis;  mem- 
branous, see  Laryngeal  diphtheria. 

Croupous  pneumonia.  See  Lobar  pneu- 
monia. 

Croup  tent,  use  of,  in  acute  laryngitis, 
433. 

Curvature  of  spine,  in  school  children, 
19;   in  sporadic  cretinism,  554. 

Cyanosis,  in  bronchopneumonia,  458; 
following  cerebral  injury  at  birth,  612; 
in  congenital  heart  disease,  485;  in 
diagnosis  between  broncho-  and  lobar 
pneumonia,  464;  in  edema  of  the 
larynx,  434;  in  acute  laryngitis,  431; 
in  multiple  neuritis,  663;  in  myocardi- 
tis, 495;  oxygen  for  relief  of,  488;  in 
paroxysmal  hemoglobinuria,  565;  in 
pericarditis,  510;  in  premature  infants, 
65;  in  stenosis  of  pulmonary  artery, 
487;  in  thyroid  enlargement,  546;  in 
valvular  heart  disease  with  failing 
compensation,  502. 

Cyclic  albuminuria.  See  Orthostatic  al- 
buviinuria. 

Cystitis,  as  complication  in  myelitis,  656. 

Cystopyelitis,  583 ;  age  as  predisposing 
factor  in,  584 ;  definition  of,  583 ;  diag- 
nosis of,  585;  drugs  in  treatment  of, 
587;  etiology  of,  584;  microorganisms 
present  in,  584,  586;  mortality  from, 
586;  operative  treatment  for,  587; 
prognosis  of,  586;  prophylaxis  of,  586; 
recurrent  vomiting  in,  585;  sex  as  pre- 
disposing cause  of,  584;  sources  of 
infection  in,  584;  symptomatology  of, 
585;  temperature  range  in,  585;  ter- 
mination of,  586;  treatment  of,  586; 
tumor  in,  585;  urine  findings  in,  586; 
X-ray  picture  in,  586,  587. 

" Cytorrhyctes  variola,"  345. 

CzERNY,  on  hydrocephalus  and  diseases  of 
adrenals,  619;  on  over-feeding  a  cause 
of  intestinal  indigestion,  174,  175;  on 
over-feeding  injurious  to  metabolism, 
175;  on  symptom  group  in  acute  in- 
testinal  indigestion,   184. 


D 


Dactylitis,  393. 


Deafness,  due  to  adenoid  growths,  425; 
following  use  of  Flexner  serum,  638; 
following  meningococcic  meningitis, 
635;  due  to  mumps,  359;  due  to  syph- 
ilis, 367. 

Death,  causes  of,  in  infancy  and  child- 
hood, 1. 

Debility,  general,  nursing  infant  contra- 
indicated  by,  112. 

Defective  interventricular  septum, 
487. 

Deglutition  pneumonia,  462. 

Dentition,  delayed,  as  a  pathological 
factor,  145;  first,  as  a  cause  of  intes- 
tinal disturbances,  176. 

Dermatitis,  in  new-born,  79;  treatment 
of,  80. 

Dermatitis  exfoliativa,  79. 

Desquamation,  in  measles,  336;  in  scar- 
let fever,  322,  327;  in  variola,  347. 

Dew's  method  of  artificial  respira- 
tion, 73. 

Dextrin,  combination  of,  with  maltose  in 
artificial  food,  125. 

Dextrinized  gruels,  use  of,  in  artificial 
feeding,  126. 

Diabetes  mellitus,  250;  toxic  nephritis 
associated  with,  572. 

Diacetic  acid,  presence  of,  in  urine  in 
acetonuria,  565;  presence  of,  in  urine 
in  measles,  336;  test  for,  with  ferrous 
chlorid,  566. 

Diarrhea,  in  cholera  infantum,  192;  in 
enteric  infection,  191;  in  acute  intes- 
tinal indigestion,  183,  186;  in  chronic 
intestinal  indigestion,  198;  in  miliary 
tuberculosis,  387;  in  peritonitis,  231; 
in  tuberculosis  of  lymph-nodes,  383; 
treatment  of,  in  tuberculosis,  400;  in 
typhoid    fever,    272,    278. 

DiAzo  reaction  of  Ehrlich,  273,  275, 
336 ;  absence  of,  in  rubella,  343. 

Dickie,  operation  by,  for  obstruction  of 
esophagus,  158. 

Diet,  as  a  means  of  controlling  putre- 
factive processes  in  intestinal  canal  of 
infants,  177. 

Diet,  errors  in,  a  cause,  of  constipation, 
204,  206 ;  of  edema,  578 ;  of  acute  gas- 
tric indigestion,  159;  of  recurrent 
vomiting,  251;  of  rickets,  237;  of 
scurvy,  246. 

Diet,  therapeutic  value  of,  in  acute  artic- 
ular rheumatism,  405,  406;  in  appendi- 
citis, 227;  in  bronchopneumonia,  465; 
in  chlorosis,  527 ;  in  chorea,  700 ;  in  con- 
genital hypertrophy  of  pylorus,  170;  in 
constipation,    206,    207;    in    diabetes, 


750 


INDEX 


250;  in  dilatation  of  the  stomach,  164; 
in  diphtheria,  307;  in  eclampsia,  684; 
in  eczema,  722;  in  edema  of  glottis, 
435;  in  acute  endocarditis,  493;  in 
enteric  infection,  193 ;  in  erythema 
multiforme,  730;  in  first  year  of  life, 
142;  in  fourth  to  sixth  year  of  life, 
143;  in  functional  heart  disease,  508; 
in  acute  gastric  indigestion,  160;  in 
acute  gastritis,  162;  in  chronic  gas- 
tritis, 172;  in  gastroduodenitis,  166; 
in  infantile  cerebral  palsies,  615;  in 
acute  infectious  disease,  as  prophylaxis 
against  nephritis,  578;  in  acute  intes- 
tinal indigestion,  188 ;  in  chronic  intes- 
tinal indigestion  of  infants,  200;  in 
chronic  intestinal  indigestion  of  older 
children,  203;  in  lobar  pneumonia,  450; 
in  malaria,  286 ;  in  measles,  339 ;  in 
meningococcic  meningitis,  638;  in  mul- 
tiple neuritis,  663;  in  mumps,  360;  in 
acute  nephritis,  580;  in  chronic  ne- 
phritis, 583;  in  nystagmus  and  head- 
nodding,  691;  in  obscure  fevers, 
266;  in  orthostatic  albuminuria,  570; 
in  pavor  nocturnus,  675;  in  acute 
pericarditis,  512;  in  peritonitis,  231; 
in  pica,  705;  in  purpura,  535;  in  re- 
current vomiting,  257;  in  rickets,  243; 
in  scarlet  fever,  329;  in  scurvy,  249; 
in  second  year  of  life,  143 ;  in  simple 
secondary  anemia,  527;  in  status 
lymphaticus,  550;  in  stomatitis  aph- 
thosa,  148;  in  stomatitis  catarrhalis, 
147;  in  stomatitis  mycosa,  150;  in 
syphilis,  369;  in  tetany,  689;  in  third 
year  of  life,  143 ;  in  tonsillitis,  423 ; 
in  tuberculosis,  397;  in  tuberculous 
peritonitis,  401;  in  typhoid  fever, 
276;  in  urticaria,  728;  in  valvular  dis- 
ease of  the  heart,  504;  in  varicella, 
357;  in  variola,  348;  in  whooping- 
cough,    292. 

Digestive  ferments,  125 ;  in  milk,  106. 

Digital  examination,  30. 

Dilatation  of  stomach,  163;  diagnosis 
of,  163;  etiology  of,  163;  prognosis  of, 
164;  symptomatology,  163;  treatment, 
164. 

Diluents,  alkaline,  139;  carbohydrates, 
138. 

Diphtheria,  295;  antitoxin  in  treatment 
of,  see  Antitoxin;  bacillus  of,  295;  ba- 
cillus of,  in  cystopyelitis,  584;  blood 
picture  in,  297;  "carriers"  of,  295; 
complications  of,  299;  course  of,  300; 
diagnosis  of,  301 ;  diagnosis  between, 
and    spasmodic   catarrhal   croup,   301; 


diet  in,  307;  drugs  in,  307;  duration 
of,  300;  etiology  of,  295;  of  the  eye, 
299;  immunity  from,  295;  incubation 
period  of,  296;  intubation  in,  304,  305; 
of  larynx,  297;  local  treatment  of  laryn- 
geal form,  304;  measles  complicated 
by,  338;  mortality  from,  2,  300; 
multiple  neuritis  due  to,  299;  myo- 
carditis as  complication  of,  299; 
paralysis  following,  299,  307;  pathol- 
ogy, 296;  predisposing  causes  of,  295; 
prognosis  of,  300;  prophylaxis  in,  302; 
quarantine  in,  302;  septicemia  as  com- 
plication of,  299,  307;  symptomatology 
of,  296;  temperature  curve  in,  297;  toxe- 
mia in,  299;  tracheotomy  in,  304; 
transmission  of,  295;  of  vulva,  299. 

Diplegia,  614;    treatment  of,  615. 

Diuretics,  use  of,  in  pleurisy  with  ef- 
fusion, 478;  contraindicated  in  acute 
nephritis,  581. 

Discharges,  gastrointestinal  in  new- 
born, 3 ;  from  intestinal  tract  in  intus- 
susception, 220. 

Diuretin,  use  of,  in  pleurisy  with  ef- 
fusion, 478. 

Douche,  nasal,  48. 

Dropsy.    See  Ascites  and  Edema. 

Drugs,  effect  of,  upon  milk  of  nursing 
mother,  112;  hematuria  caused  by, 
563;  hemoglobinuria  caused  by,  564; 
purpura  caused  by,  532;  toxic  nephri- 
tis caused  by,  573;  suited  for  use  by 
inunction,  42 ;  suited  for  use  by  mouth, 
38. 

Drugs,  employed  in  treatment  of,  acute 
articular  rheumatism,  405;  of  asthma 
during  attack,  712;  of  asthma  during 
interval,  713;  of  bronchopneumonia, 
466;  of  acute  catarrhal  bronchitis, 
441;  of  acute  cardiac  dilatation,  498; 
of  chlorosis,  528;  of  chorea,  700;  of 
congenital  dilatation  of  colon,  210;  of 
congenital  icthyosis,  731;  of  constipa- 
tion, 207;  of  dilatation  of  stomach, 
164;  of  diphtheria,  307;  of  eclampsia, 
683;  of  eczema,  723;  of  acute  endo- 
carditis, 494;  of  enteric  infection, 
195;  of  enuresis,  602;  of  epilepsy, 
696;  of  functional  heart  disease,  508; 
of  furunculosis,  729;  of  acute  gastric 
indigestion,  160;  of  acute  gastritis, 
162;  of  chronic  gastritis,  173;  of  gas- 
troduodenitis, 165;  of  headache,  710; 
of  hemophilia,  539;  of  influenza,  315; 
of  intestinal  indigestion  in  infants,  201; 
of  intestinal  indigestion  in  older  chil- 


INDEX 


751 


dren,  203;  of  acute  laryngitis,  432; 
of  lobar  pneumonia,  452;  of  measles, 
339;  of  multiple  neuritis,  664;  of 
mumps,  360;  of  acute  nephritis,  579; 
of  pericarditis,  513;  of  pernicious 
anemia,  529;  of  pleurisy,  478;  of 
poliomyelitis,  651;  of  pseudo-mastur- 
bation, 609 ;  of  rachitis,  244 ;  of  re- 
current vomiting,  256;  of  acute  rhini- 
tis, 414;  of  simple  anemia,  524;  of 
sporadic  cretinism,  556;  of  status 
lymphaticus,  550;  of  stomatitis  aph- 
thosa,  148;  of  stomatitis  catarrhalis, 
147;  of  stomatitis  ulcerosa,  151;  of 
syphilis,  370;  of  tinea  tonsurans,  734; 
of  tonsillitis,  422 ;  of  tuberculosis,  398 ; 
of  urticaria,  727;  of  valvular  heart 
disease,  504;  of  variola,  348;  of 
whooping  cough,  294. 

Dry  cupping,  in  treatment  of  acute 
nephritis,  580. 

Duchenne-erb's  palsy.  See  Upper- 
arm  paralysis. 

Ductless  glands,  enlargement  of,  in 
status  lymphaticus,   545. 

Dunn,  on  favorable  influence  of  lumbar 
puncture  in  tuberculous  meningitis, 
629;  on  value  of  cerebrospinal  fluid 
in  diagnosis  of  tuberculous  meningitis, 
629. 

DwARFiSHNESS,  association  of,  with 
endemic  cretinism,  553;  with  sporadic 
cretinism,  553,  554;  with  concealed 
tuberculosis,  383. 

Dyspnea,  presence  of,  in  acetonuria, 
566;  in  asthma,  711;  in  broncho- 
pneumonia, 457,  458;  in  acute  ca- 
tarrhal bronchitis,  440;  in  congenital 
dilatation  of  colon,  209;  in  congenital 
heart  disease,  485;  in  congenital 
laryngeal  stridor,  437;  in  edema  of 
larynx,  434;  in  acute  endocarditis, 
490;  in  Hodgkin's  disease,  541;  in 
laryngeal  diphtheria,  299;  in  acute 
laryngitis,  430,  431;  in  multiple  neuri- 
tis, 663;  in  myocarditis,  495;  in  peri- 
carditis, 510;  in  periesophageal  ab- 
scess, 158;  in  pleurisy,  473;  in  retro- 
pharyngeal abscess,  428;  in  status 
lymphaticus,  545,  546;  in  tuberculous 
bronchopneumonia,  462;  in  tubercu- 
losis of  bronchial  lymph-nodes,  382; 
in  tuberculosis  of  mesenteric  lymph- 
nodes,  383. 

Dystrophy,  progressive  muscular,  666. 

E 

Earache,  due  to  adenoid  growths,  425; 
49 


due  to  otitis  media,  715,  716;  fever 
associated  with,  262,  263,  264;  signifi- 
cance of,  in  bronchopneumonia,  463. 

Eberth,  description  of  typhoid  bacillus 
by,  267. 

Eclampsia,  678;  definition  of,  678;  diet 
in,  684;  due  to  epilepsy,  680;  e*Jology 
of,  678;  exciting  causes  of,  680;  hys- 
terical form  of,  707;  idiocy  due  to, 
623;  predisposing  causes  of,  678; 
prognosis  of,  681 ;  reflex  causes  of, 
680;  symptomatology  of,  680;  treat- 
ment of,  682. 

Eczema,  719;  crustosum,  721;  definition 
of,  719 ;  diagnosis  of,  721 ;  diet  in, 
722;  etiology  of,  719;  external  causes 
of,  720;  general  treatment  of,  721; 
internal  causes  of,  719;  local  applica- 
tions in,  723;  papular  form  of,  720; 
prognosis  of,  721;  pustular  form  of, 
721;  rubrum,  721;  squamosum,  721; 
symptomatology  of,  720;  treatment  of, 
721. 

Edebohls'  operation,  for  splitting  cap- 
sule of  kidney,  583. 

Edema,  of  glottis,  see  Edema  of  larynx; 
idiopathic  form  of,  578;  of  larynx, 
434;  in  acute  nephritis,  576,  578;  in 
tetany,  688. 

Edema,  localized,  in  Henoch's  purpura, 
534;  in  purpura  rheumatiea,  535. 

Edsal,  on  bicarbonate  of  soda  in  recur- 
rent  vomiting,   256. 

Egg  albumin,  use  of,  in  artificial  feed- 
ing of  infants,  137. 

Eggs,  soft-boiled,  in  diet  of  infants, 
142;  in  diet  of  typhoid  fever,  277. 

Ehrlich's  diazo-reaction.  See  Diazo- 
reaction. 

Ela,  on  manipulations  in  artificial  res- 
piration, 73. 

Electric  heaters,  use  of,  in  acute  neph- 
ritis, 580. 

Electricity,  therapeutic  use  of,  in  con- 
genital dilatation  of  colon,  210;  in 
facial  paralysis,  666;  in  hysteria,  708; 
in  multiple  neuritis,  664;  in  poliomye- 
litis, 652;  in  post-diphtheritic  paraly- 
sis, 309;  in  progressive  muscular  atro- 
phy,  669. 

Emetic,  value  of,  in  acute  laryngitis, 
432. 

Emphysema,  association  of,  with  asth- 
ma, 712;  with  whooping  cough,  289. 

Empyema,  bilateral,  481;  Brewer's 
method  of  drainage  in,  480;  Bryant's 
method  of  drainage  in,  480;  broncho- 
pneumonia     complicated      by,      462; 


r52 


INDEX 


chronic  form  of,  481;  pathology  of, 
471 ;  pneumococcus  in  causation  of, 
470;  respiratory  capacity  diminished 
in,  471;  surgical  treatment  of,  479; 
temperature  curve  in,  472;  treatment 
of,  during  convalescence,  482. 

Encephalitis,  a  cause  of  idiocy,  623. 

Encephalocele,  621. 

Endocarditis,  acute,  489;  in  acute 
articular  rheumatism,  404;  in  chorea, 
697;  definition  of,  489;  diagnosis  of, 
492;  diet  in,  493;  drugs  in  treatment 
of,  493 ;  etiology  of,  489 ;  in  erythema 
multiforme,  730 ;  in  fetal  life  a  cause 
of  congenital  heart  disease,  485 ;  hered- 
ity in  causation  of,  489;  in  He- 
noch 's  purpura,  534 ;  in  lobar  pneu- 
monia, 448 ;  microorganisms  present  in, 
490 ;  pathology  of,  .490 ;  physical  signs 
of,  491;  prognosis  of,  492;  prophy- 
laxis of,  492;  recurrent  attacks  of,  as- 
sociated with  rheumatism,  503 ;  septic 
form  of,  491 ;  sources  of  infection  in, 
490;  symptomatology  of,  490;  tem- 
perature curve  in,  490;  tonsillitis  as- 
sociated with,  422;  treatment  of,  493; 
ulcerative   form   of,  494. 

Enemata,  high,  for  relief,  of  eclampsia, 
683;  of  intestinal  intussusception,  222; 
of  oxynris  vermicularis,  218;  of  re- 
current vomiting,  256. 

Enemata,  rectal,  in  congenital  dilata- 
tion of  colon,  210;  in  chronic  constipa- 
tion, 207;  in  acute  intestinal  indiges- 
tion, 187;  in  chronic  intestinal  in- 
digestion, 203;  in  measles,  340;  in 
peritonitis,  232;  therapeutic  value  of, 
51;  in  tuberculous  peritonitis,  401; 
in  typhoid  fever,  278. 

Enteric  infection,  189;  cholera  infan- 
tum a  form  of,  192;  definition  of, 
189;  diarrhea  in,  191;  diet  in,  193; 
drugs  in,  195;  hygienic  treatment  of, 
197;  medicinal  treatment  of,  195; 
nervous  symptoms  in,  192;  pathology 
of,  189;  prognosis  in,  193;  stimulating 
treatment  of,  196;  symptomatology  of, 
190;  temperature  curve  in,  190,  192; 
treatment  of,  193. 

Enuresis,  598;  belladonna  in  treatment 
of,  602;  diet  in  treatment  of,  601; 
drugs  in  treatment  of,  602;  etiology 
of,  599;  exciting  causes  of,  599;  fac- 
tors in,  598,  599 ;  general  treatment  of, 
601;  habit  in  causation  of,  599;  hered- 
ity in  causation  of,  599;  malnutrition 
in  causation  of,  599 ;  medicinal  treat- 
ment of,  602;  physiology  of,  598;  pre- 


disposing causes  of,  599;  prognosis  of, 
601;  reflex  irritation  as  cause  of,  599, 
601;  symptomatology  of,  601;  treat- 
ment of,  602;  urine  findings  in,  601. 

Environment,  as  cause,  of  hysteria, 
706;  of  masturbation,  606;  of  pseudo- 
masturbation,  606. 

Enterocolitis,  association  of,  with 
scurvy,  248;  as  complication  of  influ- 
enza, 310;  as  complication  of  measles, 
338;  as  complication  of  whooping- 
cough,  290;  diagnosis  between,  and  in- 
testinal intussusception,  221;  See  also 
Enteric  infection. 

Enteritis,  as  complication  of  diphtheria, 
300. 

Epilepsy,  691;  aura  in,  693;  convulsions 
in,  694;  definition  of,  691;  diagnosis 
of,  694;  diet  in,  695;  diplegia  a  cause 
of,  614;  drugs  in  treatment  of, 
696;  eclampsia  due  to,  680;  etiology 
of, '691;  hemiplegia  associated  with, 
613;  idiocy  due  to,  623;  loss  of  con- 
sciousness in,  693;  meningeal  hemor- 
rhage a  cause  of,  611;  mental  symp- 
toms of,  694;  number  of  attacks  in, 
693 ;  prognosis  in,  694 ;  pseudomastur- 
bation  not  related  to,  607;  sugges- 
tion in  treatment  of,  696;  surgical 
treatment  of,  696;  symptomatology  of, 
692;  treatment  of,  695;  types  of,  692. 

Epispadias,  598. 

Epistaxis,  415;  in  adenoid  disease,  425; 
etiology  of,  415;  in  leukemia,  530;  in 
mumps,  359 ;  predisposing  causes  in, 
415;  in  purpura  hemorrhagica,  533; 
treatment  of,  416;  in  typhoid  fever, 
273. 

Epsom  salts.    See  Magnesium  sulphate. 

Erb,  on  causes  of  tetany,  687. 

Erb's  juvenile  type  of  progressive  mus- 
cular atrophy,  668. 

Erb's  symptom,  688,  689. 

Ergot,  purpura  due  to,  532. 

Eruption,  character  of,  in  acute  articular 
rheumatism,  404;  in  congenital  ichthy- 
osis, 730;  from  diphtheritic  antitoxin, 
304;  in  eczema,  720;  in  erythema  in- 
fectiosum,  343;  in  erythema  multi- 
forme, 730;  in  Henoch's  purpura,  534; 
in  impetigo  contagiosa,  731;  in  in- 
fluenza, 310,  311;  in  measles,  335;  in 
meningococcic  meningitis,  634;  in 
pemphigus  neonatorum,  732;  in  pur- 
pura, 531;  in  purpura  fulminans,  532; 
in  purpura  hemorrhagica,  533;  in  pur- 
pura rheumatica,  535;  in  purpura  sim- 
plex, 532;  in  rubella,  342;  in  scabies. 


INDEX 


753 


735;  in  scarlet  fever,  321;  in  sympto- 
matic purpura,  532;  in  syphilis,  363, 
364;  in  tinea  tonsurans,  733;  in  urti- 
caria, 726;  in  varicella,  355;  in  vari- 
ola, 346. 

Eruption,  following  use  of  diphtheritic 
antitoxin,  304;  following  influenza, 
310,  311;  method  of  bringing  out  in 
measles,  340;  of  pemphigoid  type  as 
complication  of  measles,  338. 

Erysipelas,  in  new-born,  80;  as  com- 
plication of  vaccinia,  353. 

Erythema,  combined  with  eczema,  720; 
combined  with  Henoch's  purpura,  534; 
combined  with  purpura  rheumatica, 
535. 

Erythema  infectiosum,  343. 

Erythema  multiforme,  729;  treatment 
of,  730. 

Erythroblasts,  515. 

Erythrocytes.  See  Red  hlood  corpus- 
cles. 

EscHERicH,  on  "blue"  bacillus  in 
epidemic  of  enteric  infection,  178;  on 
colon  bacillus  as  exciting  cause  of 
cystopyelitis,  584;  on  predisposing 
causes  of  tetany,  687;  on  streptococcus 
enteriditis  in  epidemic  of  acute  enteric 
infection,  178;  description  of  erythema 
infectiosum  by,  343. 

EscHERiCH  and  Moser,  reduction  of 
mortality  in  scarlet  fever  by,  through 
use  of  Moser 's  serum,  330. 

Esophagitis,  157. 

Esophagus,  congenital  malformation  of, 
158. 

Ether,  hypodermic  use  of,  in  diphtheria, 
307. 

Ethmoidal  sinuses,  brain  abscess  due 
to  septic  infection  of,  618;  infection 
of,  in  diphtheria,  300;  infection  of,  in 
influenza,  312. 

Eucalyptus,  use  of,  as  spray  in  scarlet 
fever,  330. 

Eucalyptus  oil,  inhalation  of,  in 
measles  with  septic  complications, 
340;  local  use  of,  in  influenza,  314. 

Euquinin,  therapeutic  use  of,  in  influ- 
enza, 313;  in  lobar  pneumonia,  452; 
in  malaria,  285;  in  acute  rhinitis,  415; 
in  whooping-cough,  293. 

Examination  of  sick  child,  28;  by 
auscultation,  32;  of  blood,  37;  of 
cerebrospinal  fluid,  37;  digital  form 
of,  30;  of  extremities,  31;  family  his- 
tory, 28 ;  by  inspection,  29 ;  by  palpa- 
tion, 30;  by  percussion,  32;  physical, 
29;    previous  medical   history,   28;    of 


reflexes,  31;  by  Rontgen  rays,  38;  of 
spinal  column,  31;  of  stools,  32;  for 
tuberculosis,  34;   of  urine,  32. 

Exercise,  muscular,  excess  of,  a  cause 
of  acute  cardiac  dilatation,  496;  ortho- 
static albuminuria  afi'ected  by,  570; 
passive  forms  of,  useful  in  hemiplegia, 
615;  restriction  of,  in  functional  heart 
disease,  504;  restriction  of,  in  valvular 
heart  disease,  502. 

Expectorants,  objections  to  use  of,  in 
bronchopneumonia,  467;  in  lobar  pneu- 
monia,  453;   in  measles,  340. 

Expectoration.     See  Sputum. 

Extremities,  examination  of,  in  illness, 
31. 

Eye,  diphtherla.  of,  299;  antitoxin  in 
treatment  of,  303;  local  treatment  of, 
304. 

Eyes,  care  op,  in  measles,  340;  in  new- 
born, 3;  in  variola,  348. 

Eye  strain,  associated  with  epilepsy, 
692 ;  as  cause  of  headache,  709. 


Face  and  head,  examination  of,  in  ill- 
ness, 29. 

Facial  expression,  in  cretinism,  553;  in 
idiocy,  623,  624;  significance  of,  in  ill- 
ness,  29. 

Facial  paralysis,  98. 

Family  history,  bearing  of,  on  illness, 
28. 

Fat,  food  value  of,  101,  103;  indigestion 
due  to  excess  of,  185;  proportion  of, 
in  buttermilk,  122;  proportion  of,  in 
condensed  milk,  127;  proportion  of, 
in  colostrum,  108;  proportion  of,  in 
Finkelstein 's  albumin  milk,  123;  pro- 
portion of,  in  malted  milk,  128;  pro- 
portion of,  in  malt  soups,  124;  pro- 
portion of,  in  modified  milk,  137; 
proportion  of,  in  skimmed  milk,  124; 
reduction  of,  advisable  in  diet  during 
hot  weather,  181;  Walker-Gordon 
preparation  furnishing,  137. 

Fatty  degeneration  of  new-born,  82. 

Fedinski  and  Nicoll,  use  of  antistrep- 
tococcic serum  by,  330. 

Fetus,  malaria  in,  281 ;  typhoid  in,  269. 

Fever,  exciting  causes  of,  in  infancy  and 
childhood,  261;  autoinfection  of  non- 
bacterial origin,  262;  excessive  mus- 
cular activity,  263;  heat  stroke,  262; 
inanition,  in  first  week  of  life,  87,  263; 
intestinal  toxemia,  261,265;  lobar  pneu- 
monia, 264;  mechanical  irritation,  262; 


754 


INDEX 


otitis  media,  264;  pyelocystitis,  264; 
reflex  irritation,  262;  septic  infection, 
265 ;  sepsis  in  second  week  of  life,  263 ; 
systemic  intoxication  of  bacterial 
origin,  261;  tuberculosis,  264;  typhoid 
fever,  265. 

Fevers,  obscure,  of  infancy  and  child- 
hood, 263;  antipyretics  in  treatment 
of,  266;  diet  in,  266;  inanition  a 
cause  of,  87,  263;  intestinal  toxemia  a 
cause  of,  261,  265;  lobar  pneumonia  a 
cause  of  264;  otitis  media,  a  cause  of, 
264;  pyelocystitis  a  cause  of,  264; 
septic  infection  a  cause  of,  265;  ty- 
phoid fever  a  cause  of,  265;  tubercu- 
losis a  cause  of,  264. 

Fibrinous  pneumonia.  See  Lobar  pneu- 
monia. 

FiLix  MAS.    See  Aspidium. 

FiNKELSTEIN's   ALBUMIN    MILK,    123;    USB 

of,  in  artificial  feeding  of  infants, 
123;  in  enteric  infection,  194;  in  in- 
testinal indigestion,  201. 

Finkelstein  AND  Meyer,  on  use  of 
casein  in  intestinal  indigestion,  102. 

Fish  tapeworm,  528,  529. 

Fischer,  Martin  H.,  on  formula  for  rec- 
tal injections  in  acute  nephritis,  579; 
on  mineral  salts  in  treatment  of 
paroxysmal  hemoglobinuria,  565;  on 
rectal  injections  in  eclampsia,  684;  on 
subcutaneous  alkaline  injections  in 
uremia,  580;  on  value  of  water  in  in- 
fant feeding,  106. 

Fissure  op  anus,  235. 

Flexner,  on  Shiga  bacillus,  178. 

Flexner  and  Lewis,  on  inoculation  of 
monkeys  with  poliomyelitis,  641. 

Flexner  serum,  action  of,  637;  dose  of, 
636;  results  of,  in  meningococcus  men- 
ingitis, 635,  637;  results  of,  in  puru- 
lent meningitis,  640;  technique  of  ad- 
■  ministration,  636. 

Flies,  in  transmission  of  acute  anterior 
poliomyelitis,  642;  in  transmission  of 
typhoid  fever,   268. 

Fluoroscopic  examination  in  pleurisy, 
476. 

Follicles  at  base  of  tongue,  enlarge- 
ment of,  in  status  lymphaticus,  547. 

Fomentations,  hot,  in  multiple  neuritis, 
663;  in  acute  nephritis,  579;  in 
pleurisy,  479. 

Fontanelles,  closure  of,  18. 

Food,  carbohydrates  in,  103;  fat  in, 
100 ;  mineral  salts  in,  104 ;  percent- 
ages, 139;  poisoning  from,  a  cause 
of   intestinal   disorders,    176;    proteins 


in,  101;  relation  of,  to  weight,  14; 
water  in,  105. 

Food  idiosyncrasies,  a  cause  of  eczema, 
719,  722;  a  cause  of  urticaria,  726. 

"Food  injuries,"  intestinal  indigestion 
from,  184,  185;  in  recurrent  vomiting, 
252. 

Foods,  additional,  in  infancy  and  early 
childhood,  142,  143;  percentage  value 
of,  139;  proprietary,  127;  value  of 
different   artificial,    118. 

"Foot-drop,"  662. 

Forchheimer,  on  accentuation  of  sec- 
ond sound  in  diagnosis  of  heart  dis- 
ease, 508;  on  adenitis  in  scarlet  fever, 
331;  on  alkali  treatment  of  rheuma- 
tism decreasing  risk  of  endocarditis, 
492;  on  acute  cardiac  dilatation  due 
to  coughing  spells  in  influenza,  496; 
on  chlorate  of  potash  in  treatment  of 
stomatitis  ulcerosa,  151 ;  on  enanthem 
of  rubella,  342;  on  enlargement  of 
muciparous  follicles  in  stomatitis 
catarrhalis,  147;  on  use  of  flexible  col- 
lodion in  adenitis,  544;  on  fungi  pres- 
ent in  stomatitis  mycosa,  148;  on  heat 
as  cause  of  gastroenteric  intoxication, 
180;  on  heatstroke  as  a  cause  of  fever 
in  infancy,  262;  on  heredity  in  eti- 
ology of  appendicitis,  223;  on  high 
enemata  in  typhoid  fever  for  relief  of 
meteorism,  278;  prescription  by,  for 
stimulating  remedy,  196;  on  splanchnic 
paralysis  following  diphtheria,  307;  on 
therapeutics  of  chlorosis,  528 ;  on 
transient  systolic  murmur  in  myocar- 
ditis, 507. 

Foreign  bodies  in  larynx,  trachea, 
AND  bronchi,  435;  prognosis  in,  437; 
use  of  X-ray  in,  436. 

Formalin  vapor  in  treatment  of  whoop- 
ing-cough, 293. 

Formaldehyde,  as  disinfectant  after 
contagious  diseases,  328,  339;  method 
of  generating,  328. 

Fowler's  solution  op  arsenic,  use  of, 
after  removal  of  neoplasms  from 
larynx,  435;  in  malaria,  286;  in  pur- 
pura, 536;  in  chronic  tuberculosis,  400. 

Frankel's  diplococcus  pneumonia, 
442. 

Freeman  on  temperature  of  pasteurized 
milk,   120. 

Freeman  pasteurizer,  121. 

Freidreich's  disease.  See  Hereditary 
ataxia. 

Fresh  air,  necessity  of,  in  infancy  and 
childhood,   l34;    necessity   of,   to   new- 


INDEX 


766 


born,  4;  therapeutic  value  of,  43;  in 
acetonuria,  567;  in  bronchopneumonia, 
464,  465;  in  lobar  pneumonia,  450; 
in  acute  nephritis,  581;  in  pleurisy, 
478;  in  pseudoleukemia,  526;  in  pur- 
pura, 535;  in  rickets,  244;  in  status 
lymphaticus,  550;  in  tuberculosis,  401. 

Friedlander,  a.,  experiments  by,  on  ef- 
fect of  X-ray  treatment  on  thymus 
gland,  549;  on  lymphocytosis  in  tuber- 
culosis of  lymph-nodes,  383;  on  uro- 
tropin  in  treatment  of  mumps,  360. 

Fright,  a  cause  of  chorea,  698. 

Frontal  sinuses,  brain  abscess  from 
septic  infection  of,  618;  infection  of, 
in  influenza,  312;  purulent  infection 
of,  in  diphtheria,  300. 

FuRUNCULOsis,  728 ;  microorganisms 
present  in,  728;  prognosis  of,  729; 
symptomatology  of,  728;  treatment  of, 
729;  in  typhoid  fever,  271,  274;  vac- 
cine therapy  for,  58,  729. 


G 


Gas  bacillus.     See  Bacillus  Welchii. 

Gastric  indigestion,  acute,  158;  etiol- 
ogy of,  158;  improper  food  a  cause 
of,  159 ;  physiological  gastric  incom- 
petency, 158;  prognosis,  159;  symp- 
tomatology, 159;   treatment,  160. 

Gastric  catarrh.    See  Chronic  gastritis. 

Gastritis,  acute,  160;  corrosive  form 
of,  161,  163;  etiology  of,  160;  non- 
corrosive  form  of,  160,  162;  pathology 
of,  160;  symptomatology  of,  162;  tem- 
perature changes  in,  161;  treatment 
of,  162. 

Gastritis,  chronic,  170;  diagnosis  of, 
171;  diet  in,  172;  etiology  of,  170; 
hygiene  in,  173;  pathology  of,  171; 
prognosis  of,  172;  stomach  washing 
in,  172;  symptomatology  of,  171; 
treatment  of,  172. 

Gastroenteritis,  after  bronchopneu- 
monia, 462;   in  influenza,  310,  314. 

Gastroduodenitis,  165. 

Gastrointestinal  disorders,  albumin 
water  of  value  in,  128;  bronchopneu- 
monia associated  with,  in  new-born, 
461;  buttermilk  of  value  in,  123; 
chorea  caused  by,  697;  drugs  in  causa- 
tion of,  39;  eczema  due  to,  719;  epi- 
lepsy associated  with,  695;  Finkel- 
stein's  albumin  milk  of  value  in,  123; 
frequency  of,  in  congenital  heart  dis- 
ease, 489;  fresh  air  of  value  in,  44; 
headache     due    to,    709;     indicanuna 


present  in,  562;  insomnia  associated 
with,  676,  677;  meat  preparations  of 
value  in,  129;  mortality  from,  in  in- 
fancy, 2;  Nestle 's  food  of  value  in, 
127;  pavor  nocturnus  associated  with, 
671;  premature  infants  susceptible  to, 
64;  rickets  associated  with,  240; 
skimmed  milk  of  value  in,  124;  urti- 
caria due  to,  726;  water  of  value  in, 
47,   128. 

Gaucher,  on  primary  splenomegaly,  552. 

Gavage,  indications  for,  50. 

Gay  and  Lucas,  on  blood  changes  in 
acute  anterior  poliomyelitis,  649. 

Gelatin,  subcutaneous  injection  of,  in 
hemophilia,  539;  in  hemorrhage  of 
new-born,  83. 

Geographical  tongue,  155. 

Gerhardt,  on  physical  signs  in  persist- 
ent patulous  ductus  arteriosus,  488. 

German  measles.     See  Bubella. 

Gibson,  on  diagnostic  value  of  discharge 
of  bloody  mucus  in  intestinal  intus- 
susception, 220. 

Gigantoblasts,  515. 

Glossitis,  desquamative.  See  Geo- 
graphical tongue. 

Glycerin  ointment,  use  of,  in  acute 
catarrhal  bronchitis,  441;  in  mumps, 
360. 

Goldberg  and  Anderson,  on  production 
of  measles  in  monkeys,  332. 

Gonococcus  of  Neisser,  in  cystopyelitis, 
584;    in  vulvovaginitis,  591,  592,  595. 

Gonococcus  vaccine,  therapeutic  use  of, 
58. 

Gout,  a  cause  of  asthma,  711 ;  of  eczema, 
722;  of  headache,  708. 

Grand  mal,  692. 

Griffith,  Crozer,  on  diagnosis  between 
appendicitis  and  lobar  pneumonia,  449 ; 
on  incubation  period  of  rubella,  341; 
on  prognosis  in  typhoid  fever,  275. 

Grozy,  experiments  by,  on  dextrimaltose 
preparations,  125. 

Gruber-Widal  reaction,  in  paratyphoid 
fever,  275;  in  typhoid  fever,  265,  269, 
273;  in  diagnosis  between  typhoid 
fever  and  tuberculous  peritonitis,  391. 

Grunbaum,  on  typhoid  fever  in  the  chim- 
panzee, 267. 

GuAiAcOL,  therapeutic  use  of,  in  acute 
catarrhal  bronchitis,  441;  in  convales- 
cence from  bronchopneumonia,  469;  in 
cystopyelitis,  587;  in  measles,  340;  in 
pseudoleukemia,  526;  in  tuberculous 
peritonitis,  401;  in  typhoid  fever,  277; 
in  urticaria,  728. 


756 


INDEX 


GuAiACOL,  inhalations  of,  in  acute  laryn- 
gitis, 433;  in  acute  rhinitis,  414. 

GUAIACOL  OINTMENT,  usG  of,  in  adenitis, 
544 ;  in  acute  catarrhal  bronchitis,  442 ; 
in  bronchopneumonia,  469 ;  in  cysto- 
pyelitis,  587;  in  measles,  340;  in 
mumps,  360;  in  tuberculosis,  398;  in 
tuberculous  bronchopneumonia,  401; 
in   tuberculous  peritonitis,   401. 

GuANiER,  description  by,  of  microorgan- 
isms in  variola,  345. 

Gummatous  ulceration,  in  late  heredi- 
tary syphilis,  367. 

Gymnastic  exercises,  therapeutic  value 
of,  53;   value  of,  in  rachitis,  245. 

"Gyeospasm,"  689. 


Habit,  a  cause  of  enuresis,  600;  a  cause 
of  pseudomasturbation,  606. 

Habit  spasm,  701;  definition  of,  701; 
etiology  of,  702;  prognosis  of,  702; 
symptomatology  of,  702;  treatment  of, 
703. 

Hadden,  W.  B.,  on  head-nodding  in 
child,   689,   690. 

Hall,  on  value  of  pressure  signs  in  lymph 
node  tuberculosis,  385. 

Hamburger,  description  of  skin  tuber- 
culides, by,  384. 

Hamill,  on  late  systolic  pulmonary  mur- 
mur, 507;  on  percussion,  32,  33. 

Hamilton,  Alice,  on  susceptibility  of 
vulvovaginal  canal  in  young  children 
to  gonorrheal  infection  during  scarlet 
fever,  591;  on  vaccine  therapy  in 
treatment  of  gonorrheal  vaginitis,  594. 

Hardaway  and  Grindon,  prescription 
by,  for  ointment  for  use  in  eczema, 
724;  for  ointment  for  use  in  tinea  ton- 
surans, 734;  for  lotion  for  use  in  urti- 
caria, 727;  on  Crocker's  method  of 
treatment  in  tinea  tonsurans,   735. 

Harelip,  156. 

Hastings,  measurements  by,  of  growth 
in  children,  collected  by,  17. 

Head  and  neck,  examination  of,  in  ill- 
ness, 30. 

Head,  measurements  of,  in  childhood,  18; 
nodding,  689 ;  palpation  of,  30 ;  posi- 
tion of,  in  illness,  significant,  29. 

Headache,  708;  anemic  form  of,  708; 
due  to  brain  tumor,  616;  etiology  of, 
708;  in  meningococcic  meningitis,  632; 
organic  form  of,  709 ;  reflex  form  of, 
709;  remedies  for  relief  of,  710;  toxic 
forms  of,  709;  treatment  of,  709;  due 
to  uremia,  576. 


Hearing,  sense  of,  in  infants,  22. 

Heart,  acceleration  of  action  in  infancy, 
483;  displacement  of,  in  pleurisy,  with 
effusion,  473,  476;  disturbance  of,  in 
acute  articular  rheumatism,  404;  dis- 
turbance of,  in  chorea,  700;  enlarge- 
ment of,  in  congenital  heart  disease, 
486. 

Heart,  disease  of,  associated  with  acute 
articular  rheumatism,  404;  displace- 
ment of,  in  pleurisy  with  effusion,  473, 
476;  disturbance  of,  in  chorea,  700; 
enlargement  of,  in  stenosis  of  pul- 
monary artery,  487;  growth  of,  in 
infancy  and  childhood,  484;  hyper- 
trophy of,  in  persistent  patulous  duc- 
tus arteriosus,  488;  murmurs,  see  Mur- 
mur; peculiarities  of,  in  childhood, 
483;  rest,  in  treatment  of  disease  of, 
504. 

Heart,  acute  dilatation  of,  496;  diag- 
nosis of,  496;  diagnosis  of,  from  peri- 
carditis, 511;  etiology  of,  496;  prog- 
nosis of,  496;  prophylaxis  of,  497; 
treatment  of,  498. 

Heart  disease,  congenital,  484;  blood 
changes  in,  486;  differential  diagnosis 
between  different  forms  of,  486;  eti- 
ology of,  484;  malformations  a  cause 
of,  485;  special  lesions  in,  486;  symp- 
tomatology of,  485;  treatment  of,  488. 

Heart  disease,  functional,  506;  ar- 
rhythmia, as  form  of,  506;  brady- 
cardia, as  form  of,  507;  diet  in,  508; 
etiology  of,  506;  frequency  of,  in 
child,  506;  murmurs  associated  with, 
507,  508;  paroxysmal  tachycardia,  as 
form  of,  506;  treatment  of,  508. 

Heart,  chronic  valvular  disease  op, 
498;  acute  articular  rheumatism,  a 
cause  of,  498;  aortic  regurgitation  a 
form  of,  501;  aortic  stenosis  a  form 
of,  501 ;  compensation  in,  502 ;  diet  in 
treatment  of,  504;  drugs  in  treatment 
of,  504;  endocarditis  in  causation  of, 
498;  etiology  of,  498;  exercise  in 
treatment  of,  504;  failure  of  compen- 
sation in,  502;  hygiene  in  treatment 
of,  504;  mitral  regurgitation  of,  499; 
mitral  stenosis  a  form  of,  500;  prog- 
nosis in,  502;  treatment  of,  503;  treat- 
ment of  failing  compensation  in,  505; 
tricuspid  regurgitation,  502. 

Heat-dissipating  mechanism,  increasing 
stability  of,  27;  relative  importance 
of,  in  child,  26. 

Heat,  inhibitory  centers.  See  Thermo- 
inhibitory  centers. 


INDEX 


757 


Heat-producing  centers.  See  Thermo- 
genic centers. 

Heat-regulating  mechanism,  develop- 
ment of,  25 ;  peculiarities  of,  in  pre- 
mature infant,  62. 

Heat  stroke,  262. 

Hebra's  formula,  725. 

Heidingsfeld,  formula  for  lotion  by, 
724;  formula  for  ointment  by,  735; 
on  treatment  of  pediculosis  eapillitii, 
737. 

Height,  at  different  ages,  17. 

Heimann,  on  demonstration  of  gonococ- 
cus  in  gonorrheal  vaginitis,  592. 

Hektoen,  on  relation  of  streptocoe- 
cemia  to  severity  of  scarlet  fever,  317. 

Hematoma  of  sternocleidomastoid 
muscle  in  new^-born,  98. 

Hematuria,  562;  in  acute  nephritis,  577; 
in  tumor  of  the  kidney,  588;  treat- 
ment of,  563. 

Hemiplegia,  612;  treatment  of,  615. 

Hemoglobin,  variations  of,  in  blood  of 
infants,  519;  in  chlorosis,  526;  in 
Hodgkin's  disease,  541;  in  pernicious 
anemia,  529;  in  pseudoleukemia,  525; 
in  simple  secondary  anemia,  523;  in 
status  lymphaticus,  547. 

Hemoglobinuria,  563;  diagnosis  be- 
tween, and  hematuria,  564;  epidemic 
form  of,  in  new-born,  82,  564;  etiology 
of,  563;  paroxysmal,  564;  due  to 
poisons,  564;  prognosis  of,  565;  treat- 
ment of,  565;  types  of,  564. 

Hemophilia,  537;  definition  of,  537; 
diagnosis  of,  539;  drugs  in  treatment 
of,  539;  etiology  of,  537;  prophylaxis 
of,  539;  serum  treatment  of,  540; 
symptomatology  of,  538;  treatment  of, 
539. 

Hemorrhage,  cerebral,  a  cause  of  men- 
tal deficiency,  623;  from  conjunctiva 
in  whooping-cough,  289;  meningeal,  a 
cause  of  infantile  palsy,  610;  from 
mucous  membranes  in  purpura,  533; 
from  the  respiratory  tract  in  whoop- 
ing-cough, 289;  in  scurvy,  248;  in  ty- 
phoid fever,  from  intestines,  272,  278. 

Hemorrhage  in  new-born,  82;  due  to 
congenital  syphilis,  83 ;  due  to  epidemic 
hemoglobinuria,  82;  etiology  of,  82; 
due  to  acute  fatty  degeneration,  82; 
from  intestines,  4;  due  to  melena  neo- 
natorum, 82 ;  prognosis  of,  83 ;  due  to 
septic  infection,  78;  transfusion  for 
relief  of,  84;  treatment  of,  83;  from 
umbilicus,  85. 

Henoch,  on  duration  of  typhoid  fever, 


269;  on  pneumonia  complicating 
measles,  337;  on  a  rare  form  of  non- 
tuberculous  peritonitis,  391. 

Henoch's  purpura,  534;  arsenic  contra- 
indicated  in,  537. 

Heredity,  influence  of,  in  causation  of 
adenoid  disease,  425;  of  appendicitis, 
223;  of  acute  articular  rheumatism, 
402;  of  asthma,  711;  of  congenital 
heart  disease,  485;  of  congenital  ich- 
thyosis, 730;  of  eclampsia,  679;  of  ec- 
zema, 719;  of  acute  endocarditis,  489; 
of  epilepsy,  691;  of  habit  spasm,  702; 
of  headache,  708;  of  hemophilia,  537; 
of  hereditary  ataxia,  657;  of  hydro- 
cephalus, 619;  of  hysteria,  705;  of 
idiocy,  623 ;  of  insomnia,  676 ;  of  mas- 
turbation, 606;  of  nystagmus,  690; 
of  orthostatic  albuminuria,  569;  in 
over- fatigue  at  school,  9;  of  pavor 
nocturnus,  671;  of  progressive  muscu- 
lar dystrophy,  666;  of  pseudomastur- 
bation,  606;  of  recurrent  vomiting, 
252;  of  sporadic  cretinism,  553;  of 
tuberculosis,  375 ;  of  urticaria,  726. 

Hernia,  associated  with  rickets,  240; 
caused  by  whooping-cough,  289;  con- 
genital, 87;  umbilical,  in  new-born,  86; 
umbilical,  in  sporadic  cretinism,  554. 

Heroin  hydrochlorate,  use  of,  in  in- 
fluenza, 314;   in  whooping-cough,  294. 

Herter,  on  indolaceturia,  562;  on  re- 
sults of  acid  intoxication,  566. 

Heubner,  on  food  consumption  in  in- 
fants, 131;  on  immunity  of  young  in- 
fants to  scarlet  fever,  315;  on  ortho- 
static albuminuria,  568,  569. 

Hexamethylenamin.     See  Urotropin. 

Hip- joint,  tuberculosis  of,  392. 

Hirshsprung,  description  by,  of  con- 
genital dilatation  of  colon,  208. 

History-taking  in  illness,  28. 

HOOHSINGER,  on  peculiarities  of  pericar- 
ditis in  children,  509;  on  physical 
signs  in  defective  septum,  488;  on  re- 
lation between  heart  weight  and  body 
weight  in  infancy,  483;  on  syphilitic 
pseudoparalysis,  365;  on  X-ray  treat- 
ment of   enlarged   thymus,   549. 

Hodge,  C.  F.,  on  changes  in  nerve  cells 
as  result  of  nervous  activity,  11. 

Hodgkin's  disease,  540;  blood  changes 
in,  541;  definition  of,  540;  diagnosis 
of,  541;  etiology  of,  540;  pathology 
of,  540;  prognosis  of,  542;  symptoma- 
tology of,  541;  temperature  changes 
in,  541;   treatment  of,  542. 

Hoffmann,   gastrostomy   performed   by, 


758 


INDEX 


in  congenital  malformation  of  the 
esophagus,   158. 

Hoffmann's  sign,  688. 

HoLDiNG-THE-BREATH  SPELLS,  in  laryn- 
gismus stridulus,  685. 

Holt,  apparatus  devised  by,  for  exam- 
ining breast  milk,  110;  on  use  of 
atropin  in  enteric  infection,  195;  on 
use  of  atropin  in  treatment  of  enure- 
sis, 602;  on  composition  of  human 
milk,  110;  on  dilatation  of  stomach, 
163;  on  gonococcus  in  vulvovaginitis, 
591;  on  method  of  obtaining  mucus 
for  examination  in  tuberculosis,  389 ; 
on  use  of  morphin  in  enteric  infection, 
195;  on  mortality  in  measles,  338;  on 
primary  cases  of  nephritis,  575;  on 
quantity  of  milk  required  by  normal 
infant,  110;  report  by,  on  gonorrheal 
arthritis,  593;  on  salicylate  of  soda  to 
control  gastric  fermentation,  173 ;  on 
skimmed  milk  in  diet  of  infants,  126; 
on  transmission  of  cancrum  oris,  152. 

Holt's  inanition  fever,  87,  263;  diag- 
nosis of,  88;  etiology  of,  88;  obscure 
rise  of  temperature  due  to,  263; 
symptomatology  of,  88;  treatment  of, 
89. 

Holt  and  Bartlett,  on  acute  anterior 
poliomyelitis,  642,  650. 

Holt  and  Northrup,  on  primary  in- 
testinal tuberculosis,  380. 

Hookworm,  presence  of,  in  pernicious 
anemia,  528,  529. 

Rowlands  and  Eichards,  on  recurrent 
vomiting,  251,  254. 

Huber,  analysis  by,  of  cases  of  menin- 
gococcic  meningitis,  632;  of  blood  ex- 
amination in  meningococcic  meningitis, 
634. 

Human  milk.    See  Milk. 

Hutchinson,  Jonathan,  formula  by,  for 
use  in  tinea  tonsurans,  734;  on  late 
hereditary  syphilis,  366. 

Hutchinson's  teeth,  146. 

Hyacin  hydrobromate,  in  chorea,  701. 

Hydrencephalocele,  622. 

Hydriodic  acid,  syrup  of.     See  Syrup. 

Hydrocele,  597. 

Hydrocephalus,  acute,  618. 

Hydrocephalus,  chronic  internal, 
618;  definition  of,  618;  etiology  of, 
619;  imbecility  associated  with,  623; 
mortality  from,  620;  pathology  of, 
619;  prognosis  of,  620;  symptoma- 
tology of,  619;  treatment  of,  620. 

Hydrochloric  acid,  therapeutic  use  of, 
in  typhoid  fever,  277. 


Hydronephrosis,  589. 

Hydrotherapy,  44;  use  of,  in  hysteria, 
708;  in  lobar  pneumonia,  451;  in  acute 
nephritis,  579;  in  purpura,  536;  in 
chronic  rheumatic  arthritis,  409 ;  in 
scarlet  fever,  329;  in  typhoid  fever, 
277;  value  of,  as  means  of  treatment, 
44. 

Hygiene,  general,  principles  of,  in  in- 
fancy and  childhood,  2. 

Hygienic  treatment,  of  bronchopneu- 
monia, 465;  of  enteric  infection,  197; 
of  chronic  intestinal  indigestion  in 
infants,  201;  of  lobar  pneumonia,  450; 
of  recurrent  vomiting,  257. 

Hymenolepis  nana,  212. 

Hypertrophy  of  heart,  in  persistent 
patulous  ductus  arteriosis,  488;  in 
chronic  valvular  heart  disease,  499. 

Hypertrophy  of  the  pylori  s,  congeni- 
tal.    See  Congenital. 

Hypodermoclysis,  48;  use  of,  in  diph- 
theria, 307;  method  of  using,  48;  use 
of,  in  nephritis,  580;  use  of,  in  scarlet 
fever,  330;  therapeutic  value  of,  48; 
use  of,  in  typhoid  fever,  278. 

Hypospadias,  597. 

Hysteria,  706;   treatment  of,  707. 


Ice,  therapeutic  use  of,  47. 

Ice-bag,  therapeutic  use  of,  in  adenitis 
of  scarlet  fever,  331;  in  acute  cardiac 
dilatation,  498;  in  cystopyelitis,  587; 
in  diphtheria,  304;  in  acute  endocardi- 
tis, 493;  in  fevers,  266;  in  headache, 
701 ;  in  heart  complications  of  acute 
rheumatism,  406;  in  Henoch's  pur- 
pura, 537;  in  intestinal  hemorrhage, 
278;  in  malaria,  286;  in  mastoiditis, 
718;  in  meningococcic  meningitis, 
638;  in  acute  pericarditis,  512;  in 
pleurisy,  478;  in  purpura  hemor- 
rhagica, 537;  in  tonsillitis,  423;  in  ty- 
phoid fever,  in  connection  with  baths, 
277,  278;   in  variola,  348. 

Ice-cap,  therapeutic  value  of,  46;  in 
eclampsia,  682;  in  lobar  pneumonia, 
451. 

Ice-cream,  a  source  of  infection  in  ty- 
phoid fever,  268. 

IcHTHYOL  OINTMENT,  therapeutic  use  of, 
in  erysipelas  of  new-born,  81;  in 
scarlet  fever,  330. 

Ichthyosis,  congenital.  See  Congenital. 

Icterus  neonatorum,  92;  symptoma- 
tology of,  93;   treatment  of,  93. 

Icterus,  other  forms  of,  in  new-born,  94. 


INDEX 


759 


Icterus,  in  toxic  nephritis,  572;  in 
Winckel's  disease,  564. 

Idiocy,  622;  acquired,  623;  amaurotic 
family,  624;  congenital,  622;  defini- 
tion of,  622;  due  to  epilepsy,  694; 
etiology  of,  622;  microcephalic,  625, 
626;  Mongolian,  554,  625;  prognosis 
of,  624;  sporadic  cretinism,  554; 
symptomatology  of,  623;  treatment 
of,  624. 

Iglauer,  on  avoidance  of  general  anes- 
thesia in  evacuation  of  retropharyn- 
geal abscess,  429. 

Imbecility,  associated  with  epilepsy, 
694;  with  infantile  cerebral  palsies, 
613,  614. 

Impetigo  contagiosa,  731;  treatment  of, 
732. 

Inanition  fever.  Holt's.    See  Bolt. 

Incontinence  op  urine,  occurrence  of, 
in  eclampsia,  681 ;  in  hypospadias, 
598;  in  myelitis,  654,  656;  in  night- 
terror,  673;  physiologically  in  infancy, 
561. 

Incubator,  66. 

Indican,  absence  of,  in  urine  of  new- 
born, 562;  derivation  of,  in  urine,  562. 

Indicanuria,  562;  in  headache,  709;  in 
chronic  intestinal  indigestion,  202;  in 
intestinal  toxemia,  265;  in  orthostatic 
albuminuria,  569 ;  a  sign  of  putre- 
factive changes  in  intestine,  205. 

Indolaceturia,  cause  of,  562;  presence 
of,  in  intestinal  toxemia,  205;  pres- 
ence of,  associated  with  putrefactive 
changes  of  intestine,  205. 

Infancy,  chief  causes  of  death  in,  1; 
clothing  in,  5;  contagion  in,  6;  fresh 
air  in,  4;  head-measurements  in,  18; 
heat-regulating  mechanism  in,  25; 
height  in,  17;  hygiene  during,  2,  10; 
malaria  in,  283;  muscular  develop- 
ment in,  20;  nervous  activity  in,  6; 
nervous  system  in,  23;  nursery  in,  5; 
peculiarities  of  blood  in,  518;  rest  in, 
4;  sleep  in,  4,  671;  special  senses  in, 
22 ;  spinal  development  in,  22 ;  suscepti- 
bility to  high  temperatures  in,  27,260; 
therapeutics  of,  38;  weight  in,  13,  15. 

Infantile  atrophy,  199. 

Infantile  cerebral  palsies,  610;  defi- 
nition of,  610;  diagnosis  of,  615;  diet 
in,  615;  etiology  of,  610;  orthopedic 
treatment  of,  616;  pathology  of,  611; 
prognosis  of,  615;  symptomatology  of, 
612;   treatment  of,  615. 

Infantile  myxedema.  See  Cretinism, 
sporadic. 


Infantile  spinal  paralysis.  See  Acute 
anterior  poliomyelitis. 

Infantile  scurvy,  246;  blood  changes 
in,  248;  curative  treatment  of,  249; 
definition  of,  246;  diagnosis  of,  248; 
diet  of,  249;  etiology  of,  246;  morbid 
anatomy  in,  247;  prognosis  of,  249; 
prophylactic  treatment  of,  249;  rheu- 
matism mistaken  for,  404;  symptoma- 
tology of,  247;  temperature  changes 
in,  248;  toxic  nephritis  associated 
with,  572;  treatment  of,  249;  urine 
findings  in,  248. 

Infection,  sources  of,  in  adenitis,  377; 
in  adenoid  disease,  425;  in  appendi- 
citis, 223;  in  acute  catarrhal  bronchi- 
tis, 438;  in  diphtheria,  295;  in  acute 
endocarditis,  490;  in  enteric  infection, 
189;  in  erythema  infectiosum,  343;  in 
gonorrheal  vulvovaginitis,  591;  in 
impetigo  contagiosa,  731;  in  influenza, 
308;  in  acute  intestinal  toxemia,  176; 
in  lobar  pneumonia,  433;  in  malaria, 
280;  in  mastoiditis,  717;  in  measles, 
332;  in  meningococcic  meningitis, 
631;  in  mumps,  357;  in  mycotic  ne- 
phritis, 574;  in  myelitis,  652;  in  myo- 
carditis, 494;  in  acute  nephritis,  572; 
in  chronic  nephritis,  584;  in  ophthal- 
mia neonatorum,  94;  in  otitis  media, 
714;  in  pericarditis,  509;  in  peritoni- 
tis, 228,  229;  in  acute  anterior  polio- 
myelitis, 642;  in  retropharyngeal  ab- 
scess, 427;  in  acute  rhinitis,  411;  in 
rubella,  341;  in  scarlet  fever,  316;  in 
sepsis  of  new-born,  75;  in  sinuses, 
frontal  and  ethmoid,  from  diphtheria, 
300;  in  syphilis,  361;  in  tetanus 
neonatorum,  89;  in  tonsillitis,  419;  in 
tuberculosis,  373;  in  tuberculous 
meningitis,  627;  in  typhoid  fever, 
268;  in  simple  vaginitis,  595;  in 
variola,  345. 

Infection,  susceptibility  to,  in  prema- 
ture infant,  64. 

Infectious  diseases,  acute,  chorea  fol- 
lowing, 697;  congenital  heart  disease 
due  to,  in  mother,  485;  cystopyelitis 
due  to,  584;  danger  from,  in  status 
lymphaticus,  550;  eclampsia  due  to, 
680;  endocarditis  due  to,  490;  enure- 
sis due  to,  599;  milk  of  nursing 
mother  affected  by,  112;  acute  ne- 
phritis due  to,  578;  mycotic  nephritis 
due  to,  574,  575;  predisposing  cause 
in  gonorrheal  infection  of  vagina, 
595;  predisposing  cause  in  transmis- 
sion of  tuberculosis,  375;  purpura  due 


760 


INDEX 


to,  532;  splenic  enlargement  asso- 
ciated with,  552;  danger  from,  in 
status  lyniphaticus,  550;  urine  ex- 
amination in,  559. 

Influenza,  308;  after-treatment  of,  315; 
bacillus  of,  308,  311;  acute  cardiac 
dilatation  due  to,  496;  characteristics 
of,  in  infancy,  311;  chronic  form  of, 
311;  climatic  influences  in,  308; 
climatic  treatment  of,  310,  314;  com- 
plications in,  311;  coryza  in,  310;  defi- 
nition of,  308;  danger  from,  in  in- 
fancy, 5;  danger  from,  to  tuberculous 
children,  595 ;  definition  of,  308 ;  diet 
in,  313;  drugs  in,  313;  etiology  of, 
308;  eruptions  in,  resembling  scarlet 
fever,  325;  gastroenteritis  in,  310, 
311;  immunity  from,  311;  incubation 
period  in,  309;  local  treatment  of,  314; 
mortality  from,  in  infancy,  2;  multi- 
ple neuritis  from,  661;  nephritis  due 
to,  312;  nervous  symptoms  in,  308; 
pathology  of,  309;  prognosis  of,  312; 
prophylaxis  of,  312;  nervous  symptoms 
in,  308 ;  pathology  of,  309 ;  prognosis 
of,  312;  prophylaxis  of,  312;  skin  erup- 
tions in,  310,  311;  sources  of  infection 
in,  308;  symptomatology  of,  309; 
symptom  groups  in,  310;  temperature 
curve  in,  309,  311;  treatment  of,  313; 
eruptions  in,  310,  311;  sources  of  in- 
fection in,  308;  symptomatology  of, 
309;  symptom  groups  in,  310;  tem- 
perature curve  in,  309,  311;  treatment 
of,  313. 

Inhalations,  in  treatment  of  acute 
laryngitis,  433;  of  laryngeal  diph- 
theria, 304;   of  acute  rhinitis,  433. 

Inhibitory  function,  development  of, 
24. 

Injections,  hypodermic,  of  adrenalin, 
307;  of  caflfein,  307,  330;  of  camphor, 
307;  of  ether,  307;  of  salt  solution, 
580;  therapeutic  value  of;  see  Hypo- 
dermoclysis. 

Injections,  intravenous,  in  acute  ne- 
phritis, 579. 

Injections,  nasal,  in  epistaxis,  of 
adrenalin,  416;  in  acute  rhinitis,  414. 

Injections,  rectal,  of  Tischer  's  alkaline 
solution  in  acute  nephritis,  579,  580; 
of  food  in  artificial  feeding,  52;  of 
olive  oil  in  constipation,  51;  of  salt 
water  in  constipation,  51,  207;  of  salt 
water  in  flushing  the  colon,  51;  thera- 
peutic value  of,  51. 

Injections,  vaginal,  in  gonorrheal 
vulvovaginitis,  594. 


Inoculation,  anti-typhoid,  276. 

Inorganic  constituents  op  milk,  104; 
necessity  of,  to  nutrition,  105. 

Insolation.    See  Heat-stroke. 

Inspection,  examination  by,  in  sick- 
ness, 29;  of  face,  29;  of  general  posi- 
tion, 30;  of  head,  29;  of  respiration, 
30;   of  skin,  30. 

Intestinal  colic,  184. 

Intestinal  discharges,  examination  of, 
in  illness,  34;  danger  in  handling,  179; 
nature   of,   in  intussusception,  220. 

Intestinal  disorders  of  infancy,  173; 
age  a  predisposing  cause,  179;  bad 
hygiene  a  predisposing  cause,  180; 
bacteria  present  in,  176,  177,  178,  179; 
bathing  in  prophylaxis  of,  182;  change 
of  climate  in  treatment  of,  181 ;  cloth- 
ing in  prevention  of,  183;  dentition  as 
a  cause  of,  176;  etiology  of,  173;  ex- 
posure to  cold  and  wet  a  cause  of, 
176;  over-feeding  a  cause  of,  175; 
predisposing  factors  in,  174;  prophy- 
laxis of,  180;  summer  heat  a  predis- 
posing factor  in,  179;  swallowing 
mucus  a  cause  of,  176. 

Intestinal  fermentation,  103. 

Intestinal  indigestion,  acute,  diagno- 
sis of,  187;  diarrhea  in,  183;  fat  indi-. 
gestion  in,  185;  food  injuries  in,  184, 
185;  nervous  symptoms  in,  184;  pain 
in,  184;  pathology  of,  183;  prognosis 
of,  187;  protein  indigestion  in,  186; 
sugar  indigestion  in,  186;  symptoma- 
tology of,  183;  symptom  group  in, 
184;  temperature  curve  in,  184;  treat- 
ment of,  187. 

Intestinal  indigestion  in  infants, 
chronic,  197;  diet  in,  200;  etiology 
of,  197;  hygienic  treatment  of,  201; 
infantile  atrophy  from,  199;  marasmus 
in,  200;  medicinal  treatment  of,  201; 
pathology  of,  198;  symptomatology  of, 
198;  treatment  of,  200. 

Intestinal  indigestion  in  older  chil- 
dren, chronic,  201;  climate  in  treat- 
ment of,  203 ;  diet  in,  203 ;  etiology  of, 
201;  medicinal  treatment  of,  203; 
prognosis  of,  203;  symptomatology  of, 
202;    treatment  of,  203. 

Intestinal  intoxication.  See  Intes- 
tinal toxemia. 

Intestinal  obstruction,  acute,  in  ap- 
pendicitis, 224. 

Intestinal  parasites.    See  Parasites. 

Intestinal  perforation,  in  typhoid 
fever,  272,  279. 

Intestinal   toxemia,   176;    a   cause  of 


INDEX 


761 


asthma,    711;    of    eclampsia,    680;    of 
fever,  261;   of  headache,  709. 

Intestinal  tubeeculosis,  380. 

Intubation,  in  acute  laryngitis,  433;  in 
edema  of  the  larynx,  434;  in  laryn-. 
geal  diphtheria,  304,  305;  method  of 
performing,  305. 

Intussusception  of  the  intestines, 
219;  course  of,  221;  definition  of,  219; 
diagnosis  of,  222;  etiology  of,  219; 
intestinal  discharges  in,  220;  pathol- 
ogy in,  220;  physical  signs  of,  221; 
prognosis  of,  221;  symptomatology  of, 
220;  temperature  curve  in,  221;  treat- 
ment of,  221;  vomiting  in,  220. 

Inunctions  op  guaiacol,  therapeutic 
use  of,  in  adenitis,  544;  in  broncho- 
pneumonia, 469;  in  acute  catarrhal 
bronchitis,  442;  in  lobar  pneumonia, 
452;  in  measles,  340;  in  pleurisy,  479; 
in  tuberculous  bronchitis,  401. 

Inunctions,  drugs  suitable  for  use  by, 
42,  43;  method  of  giving,  42;  of  oil 
in  rickets,  245 ;  in  scarlet  fever,  330 ; 
therapeutic  value  of,  41. 

"Inwakd  spasm."  See  Laryngismus 
stridulus. 

loDiD  OF  POTASH.     See  Potassium  iodid. 

loDiD  OF  iron,  syrup  OF.     See  Syrup. 

Iodin,  use  of,  by  inunction,  42,  43;  in 
chronic  pericarditis,  513;  in  pleurisy, 
479;  in  tuberculosis  of  lymph-nodes, 
399. 

Iodin,  therapeutic  use  of  internally,  in 
adenitis,  544;  in  sporadic  cretinism, 
556;  in  syphilis,  371;  in  tuberculosis, 
399. 

Iodid  of  potassium.  See  Potassium 
iodid. 

Ipecac,  syrup  of.    See  Syrup. 

Iron,  importance  of,  to  nutrition,  104; 
tincture  of  chlorid  of,  81. 

Iron,  syrup  of  iodid  of.     See  Syrup. 

Iron,  therapeutic  use  of,  in  adenitis,  544 ; 
in  asthma,  713;  in  acute  cardiac  dila- 
tation, 498;  in  chlorosis,  527,  528; 
in  chorea,  701;  in  convalescence  from 
influenza,  315;  in  convalescence  from. 
acute  laryngitis,  433;  in  convalescence 
from  lobar  pneumonia,  451;  in  enure- 
sis, 601;  in  facial  paralysis,  666;  in 
hemophilia,  539;  in  multiple  neuritis, 
664;  in  nystagmus  and  head-nodding, 
691;  in  pavor  nocturnus,  675;  in  pre- 
vention of  laryngismus  stridulus,  686; 
in  pseudoleukemia,  526;  in  pseudo- 
masturbation,  609;  in  purpura,  536, 
537 ;  in  rickets,  245 ;  in  simple  anemia, 


524;  in  status  lymphaticus,  580;  in 
tonsillitis,  423;  in  tetany,  689;  in 
valvular  heart   disease,  505. 

Irrigation,  of  bladder  in  cystopyelitis, 
587;  of  colon  in  enteric  infection,  51, 
193,  195;  of  vagina  in  gonorrheal  vul- 
vovaginitis, 594;  of  stomach;  see  Ga- 
rage. 

Insomnia,  675 ;  etiology  of,  676 ;  prophy- 
laxis of,  677;  treatment  of,  617; 
varieties  of,  676. 

Isolation,  in  influenza,  312;  in  measles, 
338;  in  mumps,  360;  in  scarlet  fever, 
327;  in  tonsillitis,  422;  in  typhoid 
fever,  276;  in  variola,  348. 

Itch.     See  Scabies. 


Jacksonian  epilepsy,  693. 

Jacobi,  on  use  of  belladonna  in  whoop- 
ing cough,  293;  on  use  of  cereals  in 
artificial  feeding,  126;  on  diet  in 
fevers,  266;  on  lymphoid  ring  of 
pharynx  as  portal  of  infection,  490; 
on  mitral  stenosis  without  a  heart 
murmur,  500;  on  peroxid  of  hydrogen 
as  an  irritant  to  the  throat,  423;  on 
rickets  as  cause  of  laryngismus  stridu- 
lus, 684;  on  relative  length  of  colon 
in  infectious  disease,  204;  on  strap- 
ping chest  for  relief  of  pain  in  pleu- 
risy, 478;  on  tonsillitis,  as  opening  for 
infection,  478;  on  uric  acid  in  infants, 
561. 

James,  apparatus  devised  by,  for  breath- 
ing exercises  after  operation  for  em- 
pyema, 481. 

Jaundice,  catarrhal  form  of;  see  Gas- 
troduodenitis ;  of  new-born;  see  Icte- 
rus neonatorum ;  in  septic  infection  of 
new-born,  77. 

Jenner,  Edward,  discovery  of  vaccina- 
tion by,  349. 

Jehle,  on  lordosis  of  lumbar  vertebrae, 
as  cause  of  orthostatic  albuminuria, 
569. 

Johnson,  W.  W.,  on  mortality  from 
whooping-cough,   291. 

Joints,  tuberculosis  of,  381,  391; 
treatment  of,  401. 

Joint  contraction  in  hysteria,  706. 


Kassowitz  and  Jacobi,  on  phosphorus 

in  treatment  of  rickets,  245. 
Keller,  on  injury  to  metabolic  processes 


762 


INDEX 


from  over-feeding,  175;  on  intestinal 
disorders  following  over-feeding,  174, 
175;  introduction  by,  of  malt  soups 
as  artificial  food  for  infants,  124;  on 
symptom  group  in  acute  intestinal  in- 
digestion, 184. 

Keratitis,  syphilitic  interstitial,  367. 

Kekley,  on  care  of  milk  in  tenements, 
182;  on  composition  of  human  milk, 
108;  on  gavage,  50;  on  method  for 
preventing  pseudomasturbation,  182 ; 
on  rectal  enemata  of  olive  oil  in  con- 
stipation, 51,  207. 

Keenig's  sigx,  significance  of,  in  sick 
child,  32;  significance  of,  in  menin- 
gococcic  meningitis,  633;  in  acute  an- 
terior poliomyelitis,  645;  in  purulent 
meningitis,  633,  635;  in  tuberculous 
meningitis,  628. 

Kidney,  cystic  degeneration  of,  589;  dis- 
location of,  590;  enlargement  of,  in 
syphilis,  359,  366;  size  of,  at  birth, 
590;  tuberculosis  of,  590. 

Kidney  tumors,  587;  etiology  of,  587; 
mortality  from,  589;  nature  of,  587; 
operative  treatment  for,  589;  symp- 
tomatology of,  588;  treatment  of,  589. 

Kilmer,  on  use  of  abdominal  belt  in 
whooping  cough,  293. 

Kirmisson,  operation  by,  for  obstruc- 
tion of  esophagus,  158. 

Kjelberg,  on  gastrointestinal  disease,  as 
cause  of  toxic  nephritis  in  infancy, 
572. 

Klebs-Lofpler  bacillus,  description  of, 
295;  in  diagnosis  between  diphtheria 
and  tonsillitis,  420;  in  etiology  of 
diphtheria,  295 ;  in  stomatitis  gan- 
grenosa, 153. 

Klein  and  Gordon,  description  by,  of 
streptococcus  scarlatina,  317. 

Knee-joint  tuberculosis,  393. 

Koch's  bacillus,  273. 

Koch's  tuberculin,  therapeutic  use  of, 
58. 

KoLMER  AND  Weston,  on  vaccins 
therapy  in  sequelae  of  scarlet  fever, 
332. 

KoNiG,  on  results  of  removal  of  thymus 
gland,  551. 

KoPLiK,  on  diagnosis  of  hypertrophy  of 
pylorus,  167,  168;  on  diagnosis  of 
pyloric  spasm,  168;  on  enanthem 
stage  of  measles,  334;  on  frequency 
of  simple  vulvovaginitis  in  children, 
595 ;  on  gonococcus  peritonitis,  230 ; 
on  gastrointestinal  disease  as  cause  of 
toxic   nephritis,   572;   on   inflammation 


of  cervix  uteri  in  gonococcus  vulvo- 
vaginitis, 592;  on  presence  of  pneu- 
mococcus  in  pleurisy  in  children,  470; 
on  presence  of  streptococcus  in   retro- 

,  pharyngeal  abscess,  248;  tables  by,  on 
physical  measurements  of  average  boys 
and  girls,  17,  18;  on  temperature  of 
milk  in  infant  feeding,  120. 

Kurth,  description  by,  of  streptococcus 
conglomeratus,  317. 

KiJSTNER,  Otto,  on  rudimentary  condi- 
tion of  genitourinary  organs  in  little 
girls,  604. 

KoPLiK  spots,  335. 


Ladd  and  Wetter,  on  influence  of  anti- 
meningitic  serum  on  joint  affection, 
635. 

La  Fetra,  on  eosinophilia  in  asthma. 

Landouzy-Dejerine  type  of  progress- 
ive muscular  dystrophy,  668. 

Landry's  paralysis,  645. 

Landsteiner  and  Popper,  on  inocula- 
tion of  monkeys  with  acute  anterior 
poliomyelitis,   641. 

Langstein,  on  symptom  group  in  acute 
intestinal    indigestion,   184. 

Lanolin,  therapeutic  use  of,  by  inunc- 
tion, 43;  in  measles,  339;  in  acute 
rhinitis,  415;  in  rickets,  245;  in  scar- 
let fever,  330;  in  varicella,  359. 

Laryngeal  stridor,  437;  treatment  of, 
438. 

Laryngismus  stridulus,  684;  defini- 
tion of,  684;  diet  in,  686;  etiology 
of,  684;  prevention  of  attack,  685; 
prognosis  of,  685;  symptomatology  of, 
685;  treatment  of  attack,  685;  treat- 
ment of  underlying  condition,  686. 

Laryngitis,  acute,  429;  definition  of, 
429;  diagnosis  of,  431;  drugs  in 
treatment  of,  432;  dyspnea  in,  431; 
etiology  of,  429;  microorganisms  pres- 
ent in,  429;  pathology  of,  430;  prog- 
nosis of,  432;  sources  of  infection  in, 
429;  spasmodic  form  of,  430;  symp- 
tomatology of,  430;  temperature  curve 
in,  431;  treatment  of,  during  attack, 
432;  treatment  of,  during  interval, 
433. 

Laryngitis,  catarrhal  form  of,  in 
measles,  337;  membranous  form  of, 
in  measles,  337,  340;  syphilitic  form 
of,  in  new-born,  364. 

Laryngospasm.  See  Laryngismus  strid- 
ulus. 


INDEX 


763 


Larynx,  diseases  of,  429;  congenital 
laryngeal  stridor,  437;  edema  of  the 
larynx,  434;  foreign  bodies  in,  435; 
acute  laryngitis,  429;  neoplasms  in, 
435. 

Lavage,  49;  in  chronic  gastritis,  172;  in 
hypertrophy  of  the  pylorus,  170. 

Laveran,  discovery  by,  of  plasmodium 
malariae,  279. 

Lead  poisoxing,  a  cause  of  multiple 
neuritis,  661. 

LE  BouTiLLiEK,  on  late  systolic  pulmo- 
nary murmur,  507. 

Ledermann,  on  Wassermann  reaction 
in  hereditary  syphilis,  368. 

Leeches,  therapeutic  use  of,  in  acute 
cardiac  dilatation,  498;  in  mastoidi- 
tis, 718. 

Leukemia,  530;  blood  picture  in,  530; 
definition  of,  530;  diagnosis  between, 
and  Hodgkin's  disease,  542;  diagnosis 
between,  and  pseudoleukemia,  525;  eti- 
ology of,  530;  lymphoid  form  of,  530; 
myeloid  form  of,  530;  prognosis  of, 
531;  symptomatology  of,  530;  tem- 
perature changes  in,  531;  treatment 
of,    531. 

Leukocytes.  See  Blood  corpuscles, 
white. 

Leukocytosis,  in  chlorosis,  527;  in 
diagnosis  of  sepsis,  265;  in  diagnosis 
of  typhoid  fever,  273;  in  diphtheria, 
297;  in  infancy,  519;  in  influenza, 
310;  in  lobar  pneumonia,  447;  in 
measles,  336;  in  meningococcic  menin- 
gitis, 634;  in  mumps,  359;  in  polio- 
myelitis, 649;  in  rubella,  343;  in 
simple  anemia,  523;  in  status  lympho- 
cytosis, 547;  in  syphilis,  366;  in 
whooping  cough,  289;  in  varicella, 
356;   in  variola,  347. 

Leveran  and  Catrin,  investigation  by, 
of  blood  in  mumps,  357. 

Ligaments,  weakness  of,  in  rickets,  240. 

Lime  water,  value  of,  in  artificial  feed- 
ing, 139. 

Lipase,  presence  of,  in  milk,  106. 

LiTHURIA,  561. 

Liver,  abscess  of,  in  lobar  pneumonia, 
448;  displacement  of,  in  pleurisy  with 
effusion,  476;  enlargement  of,  in  sim- 
ple anemia,  523;  enlargejient  of,  in 
pseudoleukemia,  531;  functional  dis- 
turbance of,  in  purpura,  532;  incom- 
petency of,  a  cause  of  recurrent  vomit- 
ing, 251. 

Loffler,  on  blood  serum,  295;  on  chil- 


dren as  carriers  of  malarial  parasites, 
281. 

Longstein,  on  depreciation  of  health  in 
orthostatic  albuminuria,  569. 

Lord,  on  leukocytosis  in  influenza,  310. 

LovETT,  table  by,  showing  increase  in 
epidemic  form  of  acute  anterior  polio- 
myelitis. 

Lumbar  puncture,  diagnostic  value  of, 
37;  in  differentiating  the  types  of 
meningitis,  640;  in  meningococcic 
meningitis,  634;  method  of,  27;  in 
acute  anterior  poliomyelitis,  651;  in 
tuberculous  meningitis,  630. 

Lungs,  enlargement  of,  in*  syphilis,  362; 
tuberculosis  of;  see  Pulmonary  tuber- 
culosis. 

Lussatti  and  Biolchini,  isolation  of 
fat-splitting  ferment   by,   106. 

LiJTHJE,  on  frequency  of  late  systolic 
pulmonary  murmur,  507. 

Lymph- ADENOMA.  See  Hodgkin's  dis- 
ease. 

Lymph  nodes,  enlargement  of,  in  adeni- 
tis, 543;  in  adenoid  disease,  543;  in 
diphtheria,  296;  in  Hodgkin's  dis- 
ease, 540,  541;  in  kidney  tumors,  588; 
in  leukemia,  530;  in  mumps,  359; 
in  retropharyngeal  abscess,  428;  in 
rubella,  342;  in  scarlet  fever,  321;  in 
status  lymphaticus,  547;  in  syphilis, 
366;  in  tuberculous  affections,  373;  in 
whooping  cough,  547. 

Lymph  nodes,  agglutination  of,  pro- 
ducing tumor  masses  in  neck  or  abdo- 
men, 547;  infection  of,  in  simple 
adenitis,  542;  inflammation  of,  in 
diphtheria,  304. 

Lymph-node  tuberculosis.  See  Tuber- 
culosis. 

Lymphocytosis,  in  lymph-node  tubercu- 
losis, 384;  in  lymphoid  form  of  leuke- 
mia, 530;  in  acute  poliomyelitis,  649; 
in  simple  anemia,  523. 

Lymphoid  ring,  417,  418. 

Lymphosarcoma,  diagnosis  between,  and 
Hodgkin's  disease,  541. 

Lymphoid  tissue,  irritability  of,  in 
measles,  342. 


Malaria,  279. 

Malformations  of  rectum  and  anus, 
233;  atresia  of  anus,  233;  congenital 
absence  of  the  rectum,  233;  fissure 
of  the  anus,  235;  polypus  of  the 
rectum,   234;    proctitis,   236;    prolapse 


764 


INDEX 


of  the  rectum,  234;  spasm  of  the  anus, 
236. 

Marasmus,  200. 

Massage,  53. 

Mastoiditis,  717. 

Measles,  332;  blood  changes  in,  336; 
complications  in,  336,  340;  contagious 
period  in,  333;  convalescent  stage  in, 
336;  definition  of,  339;  diet  in,  339; 
drugs  in,  339 ;  enanthem  stage  in,  334 ; 
etiology  of,  332;  exanthem  stage  in, 
335;  immunity  from,  333;  incubation 
period  in,  333;  method  of  bringing 
out  eruption  in,  340;  microorganism 
in,  332;  mortality  from,  338;  nervous 
symptoms  in,  336;  pathology  of,  338; 
prognosis  of,  338;  prophylaxis  in,  338; 
quarantine  in,  339;  sequelae  of,  337; 
susceptibility  to,  332;  symptomatol- 
ogy of,  334;  temperature  curve  in, 
335;  treatment  of,  339;  urine  find- 
ings of,  336. 

Meat  preparations,  129. 

Medical  treatment  in  infancy  and 
childhood,  38. 

Meningitis.  626. 

Meningitis,  cerebro-spinal.  See  Men- 
ingitis, meningococcus. 

Meningitis,  meningococcus,  631;  blood 
picture  in,  634;  "carriers"  of,  631; 
complications  of,  635;  course  of,  635; 
diagnosis  of,  634 ;  duration  of,  635 ;  eti- 
ology of,  631;  fever  in,  636;  micro- 
organism in,  631;  mortality  from,  635; 
pathology  of,  631;  prognosis  in,  635; 
prophylaxis  in,  636;  sequelae  of,  636; 
serum  treatment  of,  636;  symptoma- 
tology of,  632;  symptomatic  treatment 
of,  638;  treatment  of,  636. 

Meningitis,  purulent,  638;  definition 
of  638;  diagnosis  of,  639;  influenza 
form  of,  640;  microorganisms  present 
in,  639;  mortality  from,  639;  pneumo- 
coccus  form  of,  639 ;  staphylococcus 
form  of,  639;  streptococcus  form  of, 
639;  symptomatology  of,  639;  treat- 
ment of,  640;  typhoid  form  of,  640. 

Meningitis,  tuberculous,  626;  diagno- 
sis of,  629 ;  fever  in,  628 ;  microor- 
ganisms in,  630;  mortality  from,  627; 
pathology  of,  626;  prognosis  of,  630; 
symptomatology  of,  627;  treatment  of, 
630. 

Meningocele,  621. 

Menstrual  irregularities  in  tubercu- 
losis, 383. 

Mental  precocity,  association  of,  with 
physical  development,  7,  8,  9. 


Mercury,  inunction  of,  in  syphilis,  370. 

Microblasts,  516. 

Microcephalic  idiocy,  625;  treatment 
of,  626. 

Microcytes,  515;  in  chlorosis,  527;  in 
pseudoleukemia,  525. 

Migraine,  258. 

Milk,  condensed,  125;  cause  of  rickets, 
237;  cause  of  scurvy,  246;  value  of, 
as  artificial  food,   126. 

Milk,  breast.     See  Milk,  human. 

Milk,  cow's,  118;  carbohydrates  in, 
135,  137;  casein  in,  135;  "certified," 
119;  cleanliness  in  care  of,  118;  com- 
position of,  137;  fat  in,  135,  137; 
food  value  of,  100;  home  modification 
of,  135;  inorganic  constituents  of, 
104;  inspection  of,  118;  laboratory 
modification  of,  141;  malted,  128; 
pasteurization  of,  120;  pathogenic  or- 
ganisms transmitted  by,  177;  pepto- 
nization of,  121 ;  poisoning  by,  in  in- 
testinal indigestion,  176;  use  of,  with 
premature  infants,  68;  raw,  a  cause  of 
scurvy,  247;  Eotch  method  of  modify- 
ing, 141;  skimmed,  124;  sterilization 
of,  119;  sugar  in,  135;  tuberculosis 
transmitted  by,  376;  typhoid  fever 
transmitted   by,   268,   275. 

Milk  diet,  efl'ect  of,  on  orthostatic  al- 
buminuria, 570;  in  measles,  339;  in 
acute  nephritis,  580;  in  scarlet  fever, 
329;  in  typhoid  fever,  276. 

Milk,  human,  advantages  of,  in  enteric 
infection,  193,  195;  advantages  of,  in 
summer  heat,  181;  alexins  in,  107; 
caloric  value  of,  102;  carbohydrates 
in,  103;  casein  in,  102;  composition 
of,  107;  composition  of  colostrum  in, 
108;  digestive  ferments  in,  106;  ec- 
zema associated  with,  722;  effect  of 
nursing  upon,  113;  fat  in,  100;  food 
value  of,  101;  gastrointestinal  indi- 
gestion associated  with,  175;  impor- 
tance of,  in  bronchopneumonia,  465; 
importance  of,  in  infantile  atrophy, 
200;  importance  of,  to  premature  in- 
fants, 67;  importance  of,  in  pseudo- 
leukemia, 526;  importance  of,  in  syph- 
ilis, 309;  inorganic  constituents  of, 
104;  modification  of.  111;  proteins  in, 
102;  relation  of,  to  human  feeding, 
100;  sugar  in,  103;  water  in,  105; 
wholesomeness  of,  determined,  105. 

Milk,  malted,  128;  a  cause  of  rickets, 
237,  243;  in  diet  of  typhoid  fever, 
274. 

Milk  of  magnesia,  therapeutic  use  of, 


INDEX 


7G5 


in    eczema,    722;    in    acute    nephritis, 
579;    in  pseudoleukemia,   526. 
Milk,  modified,   135;  value  of,  in  syph- 
ilis,  369. 
Milk,  pasteurized,   120;   scurvy  due  to, 

246. 
Milk,    peptonized,    121;    value    of,    in 

pseudoleukemia,  526. 
Milk,    sterilized,    119;    scurvy    due   to, 

246. 
Milk  sugar,  intestinal  indigestion  due 
to,  103,  125;  proportion  of,  in  cow's 
milk,  103;  proportion  of,  in  human 
milk,  103;  value  of,  in  artificial  feed- 
ing, 125. 
Miliary    tuberculosis,    387;    treatment 

of,  401, 
Mills,  on  movements  of  the  eyes  in  in- 
fants,  690. 
Mineral   salts,  necessity  of,  to  nutri 

tion,  105 ;  presence  of,  in  milk,  104. 
Minor,  on  the  geographical  distribution 

of  scarlet  fever,  316. 
Mitral  regurgitation,  499;  association 
of,  with  mitral  stenosis,  501;  progno- 
sis of,  502;  treatment  of,  503. 
Mitral    stenosis,    500;    association   of, 
with   mitral   regurgitation,   501 ;   prog- 
nosis of,  502;   treatment  of,  503. 
Mixed    feeding,    114;    use    of,    in    hot 

weather,   181. 
Mongolian    idiocy,    624;    diagnosis   be- 
tween,  and   idiocy   of   cretinism,   554; 
treatment   of,  625. 
Monoplegia,  614. 
Monsel's  solution,  540. 
Monti,    on    temperature   of   milk   in   in-. 

fant  feeding,  120. 
MoRO  tuberculin  test,  diagnostic  value 
of,  36;  in  lymph-node  tuberculosis, 
385;  in  tuberculous  meningitis,  627, 
629 ;  technique  of,  36. 
MoRPHiN,  therapeutic  use  of,  in  chorea, 
701;  in  acute  cardiac  dilatation,  498; 
in  eclampsia,  683;  in  acute  endocardi- 
tis, 493;  in  enteric  infection,  195;  in 
Henoch's  purpura,  587;  in  intestinal 
hemorrhage  in  typhoid  fever,  278;  in 
intestinal  indigestion,  188;  in  kidney 
tumor,  589;  in  meningococcic  menin- 
gitis, 638 ;  in  acute  nephritis,  580,  581 ; 
in  acute  pericarditis,  513;  in  purulent 
meningitis,  640;  in  recurrent  vomit- 
ing, 256 ;  in  variola,  348 ;  in  whooping 
cough,  294. 
Morse,  on  gastrointestinal  indigestion 
as  a  cause  of  toxic  nephritis,  572;  on 
indirect   contagion  in  whooping-cough, 


287;  on  temperature  curve  in  typhoid 
fever,  270;  on  toxic  nephritis  in  pneu- 
monia and  meningitis,  572. 
Mortality,  in  appendicitis,  227;  in 
bronchopneumonia,  464;  causes  of,  in 
infancy,  1;  in  congenital  dilatation 
of  the  colon,  209;  in  congenital  hyper- 
trophy of  the  pylorus,  169;  in  cysto- 
pyelitis,  586;  in  diphtheria,  301;  in 
diplegia,  615;  in  Hodgkin's  disease, 
542;  in  hydrocephalus,  618,  620;  in 
kidney  tumor,  589;  in  lobar  pneu- 
monia, 449;  in  measles,  388;  in 
meningococcic  meningitis,  635;  in 
paraplegia,  615;  in  acute  anterior 
poliomyelitis,  650;  among  premature 
infants,  65;  reduction  of,  in  diph- 
theria, under  antitoxin  treatment,  302; 
reduction  of,  in  meningitis  under 
Flexner  serum,  637;  reduction  of,  in 
small-pox  under  vaccination,  350;  in 
scarlet  fever,  325 ;  in  septic  endocardi- 
tis, 491;  in  septic  infection  of  new- 
born, 79;  in  status  lymphaticus,  548; 
in  stomatitis  gangrenosa,  153;  in 
tetanus  neonatorum,  91;  in  tubercu- 
lous meningitis,  627,  630;  in  typhoid 
fever,  275;  in  ulcerative  endocarditis, 
494;  in  variola,  350;  in  whooping 
cough,  291. 
Movements,     passive     and     arrested, 

therapeutic  uses  of,  53. 
Mucous    patches    in    the    new-born, 

363,  364. 
Mucus,  svtallowing  or,  a  cause  of  in- 
testinal disorders,  177. 
Mumps,  357;  complications  of,  359;  con- 
tagious period  in,  358;  definition  of, 
357;  diagnosis  of,  359;  diet  in,  360; 
drugs  used  in,  360;  etiology  of,  357; 
microorganisms  in,  357;  orchitis  in, 
360;  prophylaxis  in,  360;  sources  of 
infection  in,  357;  symptomatology  of, 
358;  temperature  curve  in,  359;  trans- 
mission of,  357;  treatment  of,  360. 
Murmurs,  cardiac,  in  aortic  regurgita- 
tion, 501;  in  aortic  stenosis,  501;  in 
acute  cardiac  dilatation,  496;  in 
definite  interventricular  septum,  487; 
in  diagnosis  between  endocarditis  and 
pericarditis,  490;  in  acute  endocardi- 
tis, 490;  functional,  507;  in  mitral 
regurgitation,  499;  in  mitral  stenosis, 
561;  in  myocarditis,  495;  in  chronic 
pericarditis,  514;  in  persistent  patu- 
lous ductus  arteriosus,  488;  in  scarlet 
fever,  325;  systolic,  486;  in  stenosia 
of  the  pulmonary  artery,  487. 


766 


INDEX 


Murmurs,  friction,  in  acute  pericardi- 
tis, 510;  in  chronic  pericarditis,  514; 
in  pleurisy,  475. 

Murmurs,  hemic,  in  anemia,  523;  in 
chorea,  697,  700;  in  functional  heart 
disease,  508;  in  habit  spasm,  702. 

Murphy,  on  aspiration  for  empyema, 
480. 

Muscular  contractures,  in  chorea, 
698;  in  habit  spasm,  702;  in  infantile 
cerebral  palsies,  613,  615;  in  acute 
anterior  poliomyelitis,  646;  in  tetany, 
686. 

Muscular  exercise,  therapeutic  value 
OP,  52. 

Muscular  system,  development  of,  20. 

MussER,  on  angina  sine  dolor,  497. 

Mustard  plaster,  therapeutic  use  of, 
in  lobar  pneumonia,  451;  in  pleurisy, 
478;  objections  to,  in  broncho-pneu- 
monia,  468. 

Myelocytes,  517;  in  leukemia,  530;  in 
pernicious  anemia,  529. 

Myelitis,  653;  definition  of,  653;  dis- 
seminated forms  of,  656;  etiology  of, 
653 ;  microorganisms  in,  653 ;  paraly- 
sis in,  654,  655;  prognosis  of,  655; 
serum  treatment  of,  656;  symptoma- 
tology of,  653;  syphilitic,  655,  657; 
temperature  curve  in,  656;  transverse 
forms  of,  653;  tuberculous  form  of, 
655,  656. 

Myocarditis,  494;  as  cause  of  acute 
cardiac  dilatation,  496;  as  complica- 
tion of  bronchopneumonia,  463 ;  as 
complication  of  acute  articular  rheu- 
matism, 404;  etiology  of,  494;  inter- 
stitial form  of,  495;  parenchymatous 
form  of,  495;  prognosis  of,  495; 
prophylaxis  of,  497;  symptomatology 
of,  495;   treatment  of,  498. 

Myxedema.     See  Endemic  cretinism. 

N 

Nasal  douche,  47. 

Nasal  obstructions,  pavor  nocturnus 
due  to,  672,  675. 

Nasal  mucous  membrane,  diseases  of, 
411. 

Nasal  sinuses,  disease  of,  448. 

Nauheim  baths,  in  treatment  of  valvu- 
lar heart  disease,  505. 

Neisser's  gonococcus.  See  Gonoeoccus 
of  Neisser. 

Neoplasms  of  larynx,  435. 

Nephritis,  acute,  571;  albuminuria  in, 
576;  casts  in,  576;  complications  in, 
577;     as    complication    of    diphtheria. 


,  300;  as  complication  of  purpura,  534, 
535;  as  complication  of  scarlet  fever, 
324;  course  of,  577;  definition  of,  570; 
diet  in,  580;  dropsy  in,  576;  drugs 
used  in  treatment  of,  581 ;  idiopathic 
form  of,  576;  microorganisms  present 
in,  571;  mycotic  form  of,  574;  pro- 
phylaxis, 578;  sources  of  infection  in, 
572;  symptomatology  of,  575;  tempera- 
ture curve  in,  577;  toxic  form  of,  572; 
treatment  of,  578;  uremia  in,  576; 
urine  findings  in,  576;  varieties  of, 
572. 

Nephritis,  chronic  diffuse,  582;  treat- 
ment of,  582. 

Nephritis,  mycotic,  574. 

Nephritis,  toxic,  572;  treatment  ol, 
573. 

Nerves,  diseases  of  peripheral,  661. 

Nervous  diseases,  general,  669. 

Nervous  disturbances,  in  adenoid  dis- 
ease, 425;  in  anemia,  523;  in  chloro- 
sis, 527;  in  congenital  idiocy,  623;  in 
enteric  infection,  192;  eruption  of 
permanent  teeth  accompanied  by,  146', 
in  influenza,  310;  in  acute  intestinal 
indigestion,  184;  mother's  milk  af- 
fected by.  111;  in  acute  nephritis, 
581;  in  purpura,  532;  in  rickets,  240; 
in  scarlet  fever,  325;  in  septic  infec- 
tion, of  new-born,  78;  due  to  thyroid 
intoxication,  557,  558;  in  typhoid 
fever,  272;   due  to  uric  acid,  562. 

Nervous  system,  development  of,  23; 
excessive  activity  injurious  to,  6;  im- 
perfect development  of,  in  premature 
infants,  62;  shock  to,  dangerous  in 
status   lymphaticus,   550. 

Nestl^'s  food,  127;  advantages  of,  in 
summer,  181;  use  of,  in  acute  gastri- 
tis, 162;  use  of,  in  chronic  gastritis, 
173 ;  use  of,  in  intestinal  indigestion, 
178;  rickets  caused  by,  237,  243;  use 
of,  in  typhoid  fever,  277. 

Netter,  on  pneumococcus,  as  cause  of 
pleurisy  in  child,  470. 

Neuritis,  multiple,  661;  definition  of, 
661;  diagnosis  of,  663;  diet  in,  663; 
drugs  used  in  treatment  of,  663 ;  eti- 
ology of,  661 ;  pathology  of,  661 ; 
symptomatology  of,  662;  treatment  of, 
663. 

Neuritis,  optic,  as  symptom  of  brain 
abscess,  618;  as  symptom  of  brain 
tumor,  617. 

Neurotonic  reaction,  688. 

Neutrophiles,  517. 

New-born  infant,  albuminuria  in,  568; 


INDEX 


767 


asphyxia  in,  69;  bronchopneumonia  in, 
464;  care  of,  2;  cephalhematoma  in, 
97;  clothing  of,  5;  congenital  atelec- 
tasis in,  75;  congenital  hernia  in,  86; 
congenital  syphilis  in,  83,  361;  derma- 
titis exfoliativa  in,  79;  diseases  of, 
69;  eclampsia  in,  680,  681;  epidemic 
hemoglobinuria  in,  82,  564;  epistaxis 
in,  415;  erysipelas  in,  80;  eyes  in,  3; 
facial  paralysis  in,  98 ;  acute  fatty 
degeneration  in,  83;  fresh  air  neces- 
sary for,  4;  gonococcus  vulvovaginitis 
in,  591 ;  heat-regulating  apparatus  in, 
25;  hematoma  of  sternocleidomastoid 
muscle  in,  98;  hematuria  in,  563; 
hemorrhage  in,  81;  icterus  in,  92;  in- 
anition fever  in,  87;  incontinence  of 
urine  in,  561;  mastitis  in,  87;  melena 
neonatorum  in,  82;  nervous  system  in, 
23 ;  occlusion  of  bile-ducts  in,  93 ;  oph- 
thalmia in,  94;  peculiarities  of  respira- 
tory apparatus  in,  410;  rest  for,  4; 
sepsis  in,  263;  sleep  for,  671;  special 
senses  in,  22;  septic  infections  in, 
75;  structure  of  spine  in,  19;  sup- 
pression of  urine  in,  561;  temperature 
in,  25;  tetanus  in,  89;  typhoid  fever 
in,  269;  umbilical  affections  in,  84; 
umbilical  hernia  in,  85;  weight  of,  15. 

Night-terror,  672;  symptomatology  of, 
674;    treatment   of,   675. 

Nipples,  care  of,  113;  in  stomatitis 
mycosa,   149. 

Nitre  paper  inhalation  of  fumes  from, 
in  asthma,  712. 

Nitroglycerin,  therapeutic  use  of,  in 
asthma,  712;  in  acute  cardiac  dilata- 
tion, 498;  in  lobar  pneumonia,  463. 

Noma.     See  Stomatitis  gangrenosa. 

Normoblasts,  515. 

NoRTHRUP,  experiments  by,  showing 
danger  of  food  pneumonia,  306;  on 
fresh  air  in  bronchopneumonia,  465; 
on  fresh  air  in  lobar  pneumonia,  450; 
on  fresh  air  as  therapeutic  measure, 
43,  44;  on  rest  cure  in  neurotic  dis- 
turbances, 53;  on  scurvy  in  infants, 
246;  on  sleeplessness  in  infants,  4. 

Nose,  disease  in  accessory  sinuses  of,  as 
complication  of  lobar  pneumonia,  448; 
disinfection  of,  a  protection  against 
recurring  attacks  of  endocarditis,  493; 
foreign  bodies  in,  416;  removal  of  dis- 
eased tissue  from,  a  protection  against 
tuberculosis,  395 ;  ulceration  of,  in  late 
hereditary  syphilis,  367. 

Nursery,  5. 

NUBSING  of  infants,  adenoid  growths 
50 


an  obstacle  to,  426;  retropharyngeal 
abscess,  an  obstacle  to,  428;  rules  for, 
113. 

Nux  VOMICA,  tincture  op,  therapeutic 
use  of,  in  asthma,  713;  in  acute  endo- 
carditis, 494. 

Nystagmus  and  head-nodding,  689; 
character  of  movements  iu,  689;  defi- 
nition of,  689;  etiology  in,  690;  prog- 
nosis in,  691;  treatment  of,  691. 

O 

Obscure  fever,  263;  use  of  antipy- 
retics in,  266;  diet  in,  266;  inanition 
fever  a  cause  of,  263;  intestinal  toxe- 
mia a  cause  of,  265;  lobar  pneu- 
monia a  cause  of,  264;  otitis  media 
a  cause  of,  264;  pyelocystitis  a  cause 
of,  264;  sepsis  a  cause  of,  263;  septic 
infection  a  cause  of,  265 ;  treatment  of, 
265;  tuberculosis  a  cause  of,  264;  ty- 
phoid fever  a  cause  of,  265. 

O'Dwyeb,  Dr.  Joseph,  on  intubation 
for  relief  of  laryngeal  diphtheria,  305. 

O'DWYER   INTUBATION    SET,   305. 

Oilskin  jacket,  use  of,  in  broncho- 
pneumonia, 468;  use  of,  in  acute 
catarrhal  bronchitis,  442;  contraindi- 
cations to,  in  lobar  pneumonia,  451. 

Ointments  in  treatment  of  eczema, 
724. 

Oligochromemia,  516. 

Oligocythemia,  516. 

Ophthalmia,  diphtheritic,  299. 

Ophthalmia  neonatorum,  94;  diagno- 
sis of,  95;  etiology  of,  94;  prognosis 
of,  96;  prophylaxis  in,  96;  symptoma- 
tology of,  95;  treatment  of,  96. 

Opisthotonos,  in  lobar  pneumonia,  449; 
in  meningococcie  meningitis,  632;  in 
tuberculous  meningitis,  628. 

Opium,  therapeutic  use  of,  in  appendi- 
citis, 227;  in  brain  abscess,  618;  in 
acute  endocarditis,  493;  in  enteric  in- 
fection, 195;  during  infancy,  40;  in 
influenza,  314;  in  acute  intestinal  in- 
digestion, 188;  in  kidney  tumor,  589; 
in  lobar  pneumonia,  453;  in  menin- 
gococcie meningitis,  638;  in  peritoni- 
tis, 232;  in  acute  anterior  poliomye- 
litis, 651;  in  recurrent  vomiting,  256; 
in  typhoid  fever,  278;  in  whooping- 
cough,  294. 

Opium,  contraindications  to  use  of,  in 
bronchopneumonia,  467;  in  cough  of 
tuberculosis,  400;  in  measles,  340;  in 
multiple  neuritis,  664. 

"Opsonins,"  55. 


768 


INDEX 


Opsonic  index,  56. 

Orange  juice,  use  of,  in  constipation, 
206,  207;  in  diet  of  infants,  137,  142, 
143;  in  scurvy,  249;  in  typhoid  fever, 
277. 

Orchitis,  as  complication  of  mumps, 
359. 

Orthopedics,  in  treatment  of  hemi- 
plegia, 615;  in  treatment  of  hereditary 
ataxia,  658. 

Orthostatic  albuminuria,  568;  defini- 
tion of,  568;  diet  in,  570;  etiology  of, 
569;  prognosis  of,  570;  symptomatol- 
ogy of,  569;  treatment  of,  570;  urine 
findings   in,   569. 

OsLER,  on  appearance  of  skin  in  He- 
noch's purpura,  534;  on  aspiration  in 
acute  pericarditis,  513;  on  cardiac 
murmurs  in  chorea,  700;  on  cause  of 
pain  in  Henoch's  purpura,  534;  on 
sarcomatous  nature  of  kidney  tumors 
in  child,  587;  on  typhoid  fever  in 
autumn,  268. 

Osteochondritis,  syphilitic,  362. 

Osteomyelitis,  acute,  as  complication 
of  bronchopneumonia,  463;  as  compli- 
cation of  lobar  pneumonia,  448;  mis- 
taken for  articular  rheumatism,  405. 

Otitis,  chronic,  in  late  hereditary  syph- 
ilis, 367. 

Otitis   interna,  headache   from,   709. 

Otitis  media,  714;  due  to  adenoid  dis- 
ease, 425;  brain  abscess  caused  by, 
617,  618;  bronchopneumonia  compli- 
cated by,  463;  acute  catarrhal  bron- 
chitis, complicated  by,  439;  diphtheria 
complicated  by,  300;  etiology  of,  714; 
facial  paralysis  caused  by,  664,  665; 
influenza  complicated  by,  311;  inter- 
mittent fever  caused  by,  715;  lobar 
pneumonia  complicated  by,  448;  mas- 
toiditis caused  by,  717;  microorgan- 
isms present  in,  714;  mumps  compli- 
cated by,  359;  obscure  fever  caused 
by,  264;  operative  treatment  for,  716; 
otoscopic  examination  in,  715;  prog- 
nosis of,  716;  prophylaxis  of,  716; 
scarlet  fever  complicated  by,  324,  331; 
sources  of  infection  in,  714;  symp- 
tomatology of,  714;  temperature  curve 
in,  715;  tonsillitis  complicated  by, 
419;  treatment  of,  716;  typhoid  fever 
complicated  by,  274. 

Out-door  play,  therapeutic  value  of,  54. 

Ovaritis,  as  complication  of  mumps, 
359. 

Over-feeding,  as  a  cause  of  indigestion 
in  infancy,  133,  175. 


Oxybutyric  acid,  presence  of,  in  urine, 
565. 

Oxalic  acid,  excess  of,  in  urine  in 
orthostatic   albuminuria,   569. 

Oxygen,  inhalation  of,  in  asphyxia 
neonatorum,  73,  74;  in  bronchopneu- 
monia, 466;  in  lobar  pneumonia,  453; 
in  tuberculous  bronchopneumonia,  466. 

OxYURis  vermicularis,  217;  diagnosis 
of,  218;   treatment  of,  218. 


Packs,  cold,  use  of,  in  lobar  pneu- 
monia, 451;  objections  to,  in  acute 
catarrhal  bronchitis,  442;  use  of,  in 
obscure  fevers  of  childhood,  267;  re- 
stricted use  of,  in  bronchopneumonia, 
468;  use  of,  in  scarlet  fever,  329; 
temperature  of,  45;  therapeutic  value 
of,  45;   use  of,  in  typhoid  fever,   277. 

Packs,  hot,  use  of,  in  acute  nephritis, 
579. 

Packard,  Dr.  Frederick,  on  tonsillitis 
preceding  endocarditis,  490;  on  ton- 
sillitis preceding  infectious  diseases, 
417. 

Padded  basket,  use  of,  for  premature 
infants,  66. 

Palate,  destructive  ulceration  of,  in  late 
hereditary   syphilis,    367. 

Palpation,  value  of,  in  physical  exami- 
jiation,  30. 

Paracentesis,  in  ascites  due  to  valvular 
heart  disease,  506;  in  otitis  media, 
716. 

Paralysis,  cardiac,  in  diphtheria,  299; 
in  multiple  neuritis,  663. 

Paralysis,  facial,  664;  diagnosis  of, 
665;  drugs  in,  666;  etiology  of,  664; 
in  new-born,  97;  operative  treatment 
for,  666;  in  acute  anterior  polio- 
myelitis, 645;  prognosis  of,  665; 
symptomatology  of,  664;  treatment  of, 
666. 

Paralysis,  motor,  in  hysteria,  705;  in 
multiple  neuritis,  662;  in  myelitis, 
654;  in  acute  anterior  poliomyelitis, 
647;    in   spina  bifida,   660. 

Paralysis,  post-diphtheritic,  299,  307. 

Paralysis,  pseudo,  in  syphilis,  365. 

Paralysis,  splanchnic,  in  diphtheria, 
299,  307;  in  influenza,  312,  314;  in 
lobar   pneumonia,   448. 

Paraphimosis,  596. 

Paraplegia,  614;   treatment  of,  615. 

Parasites,  intestinal,  211;  ascaris 
lumbricoides,      215 ;       bothriocephalus 


INDEX 


769 


latus,212;  hymenolepis  nana,  212;  oxy- 
uris  vermicularis,  217;  tenia  elliptica, 
213;  tenia  saginata,  211;  tenia  soli- 
um, 212;  trichuris  trichiura,  217. 

Pabathyroid  metabolism,  defect  in,  a 
cause  of  muscle  spasm,  686. 

Paratyphoid  fever,  diagnosis  between, 
and  typhoid,  275. 

Paregoric,  therapeutic  use  of,  for  cough 
in  measles,  339;  in  earache,  716;  in 
enteric  infection,  195;  in  acute  gastri- 
tis, 162;  in  acute  intestinal  indiges- 
tion, 188;  in  kidney  tumor,  689;  in 
lobar  pneumonia,  463;  in  pleurisy, 
478;  in  tuberculous  peritonitis,  410; 
in  typhoid  fever,  278;  in  whooping- 
cough,   294. 

Park,  Dr.  W.  H.,  on  diphtheria  in  ani- 
mals, 295;  on  management  of  tene- 
ment houses,  182. 

Parke,  Dr.  Thomas  D.,  on  recurrent 
vomiting,  255. 

Parotitis,  epidemic.     See  Mumps. 

Parotitis,  as  complication  of  typhoid 
fever,  274,  276. 

Pasteurized  milk,  120. 

Patellar  reflex,  examination  of,  in  ill- 
ness, 31;    in  diphtheria,  299. 

Payor  noctubnus,  671 ;  central  type  of, 
672;  clinical  pictures  of,  674;  defini- 
tion of,  671;  etiology  of,  671;  excit- 
ing causes  of,  672;  predisposing 
causes  of,  671;  prognosis  of,  675; 
symptomatic  type  of,  674;  symptoma- 
tology of,  672;   treatment  of,  675. 

Pavy,  on  orthostatic  albuminuria,   568. 

Peacock  and  Keith,  on  stenosis  of  pul- 
monary artery,  487. 

Pediculosis  capillitii,  736;  treatment 
of,  737. 

Pemphigoid  ulcerations,  as  complica- 
tion of  measles,  338. 

Pemphigus  neonatorum,  732;  diagnosis 
between,  and  syphilitic  pemphigus  in 
new-born,  364;  treatment  of,  733. 

Pemphigus,  syphilitic,  364. 

Pepsin,  elixir  of,  as  vehicle  for  drugs, 
39;  essence  of,  as  vehicle  for  drugs, 
39. 

Percentage  feeding,  value  of,  129. 

Percentages  in  food  formulas,  139. 

Percussion,  value  of,  in  physical  exami- 
nation of  child,  32. 

Pericarditis,  acute,  509;  complicating 
acute  articular  rheumatism,  404;  com- 
plicating bronchopneumonia,  463 ; 
course  of,  512;  definition  of,  509; 
diagnosis   of,   511;    diet   in,   512;    eti- 


ology of,  509;  complicating  Henoch's 
purpura,  534;  complicating  lobar 
pneumonia,  448;  microorganisms  pres- 
ent in,  509;  operative  treatment  for, 
513;  pathology  of,  509;  physical  signs 
of,  510;  prognosis  of,  512;  prophy- 
laxis of,  512;  sources  of  infection  in, 
509;  temperature  curve  in,  510;  treat- 
ment of,  512;  varieties  of,  509. 

Pericarditis,  chronic,  513;  diagnosis 
of,  514;  etiology  of,  514;  physical 
signs  in,  514;  results  of,  514;  symp- 
tomatology of,  514;  treatment  of,  514. 

Periesophageal  abscess,  157. 

Peroneal  type  of  progressive  muscu- 
lar dystrophy,  668. 

Perinephritis,  590. 

Periostitis,  due  to  late  hereditary  syph- 
ilis, 367. 

Peritonitis,  acute,  228;  complicating 
appendicitis,  229;  etiology  of,  228; 
exciting  causes  of,  228;  complicating 
lobar  pneumonia,  448;  microorganisms 
present  in,  228;  pathology  of,  229; 
physical  examination  in,  231;  progno- 
sis of,  231;  symptomatology  in,  229; 
temperature  curve  in,  230;  treatment 
of,  231. 

Peritonitis,  tuberculous,  diagnosis  of, 
390;  pathology  of,  381;  treatment  of, 
401. 

Peritonsillar  abscess,  421. 

Perleche,  154;  treatment  of,  155. 

Permanganate  of  potash.  See  Potas- 
sium permanganate. 

Pernicious  anemia,  528. 

Peroxid  of  hydrogen,  therapeutic  use 
of,  in  acute  anterior  poliomyelitis, 
651 ;  in  tonsillitis,  423 ;  in  umbilical 
infection  of  the  new-born,  80. 

Persistent  patulous  ductus  arterio- 
sus, 488. 

Pertussis.     See  Whooping-Cough. 

Peterson,  on  rotary  head  movements  in 
infants,  689. 

Petit  mal,  692. 

Pfaundleb,  on  agglutination  reaction  in 
cystopyelitis,  584. 

Pfeiffeb,  discovery  by,  of  influenza 
bacillus,  308,  309. 

Pfeiffer's  bacillus.  See  Influenza 
bacillus. 

Pharyngitis,  in  adenoid  disease,  425; 
in  influenza,  310;  preceding  acute 
laryngitis,  430;   in  acute  rhinitis,  413. 

Pharynx,  destructive  ulceration  of,  in 
late  hereditary  syphilis,  367;  diseases 
of,    424;    removal    of    diseased    tissne 


770 


INDEX 


from,   a   protection   against   tuberculo- 
sis, 395. 
Phexacetix,  therapeutic  use  of,  contra- 
indicated    in    bronchopneumonia,    467; 
in  acute  catarrhal  bronchitis,  441 ;   in 
fevers  of  infancy  and  childhood,  267; 
in   headache,    710;    in    influenza,   313; 
in  kidney  tumor,  589;   in  lobar  pneu- 
monia,    452;     in     malaria,     286;     in 
measles,  340;   in  mumps,  340;  in  mul- 
tiple  neuritis,   664;    in   acute  anterior 
poliomyelitis,  651;  in  rubella,  343;  in 
tonsillitis,    278;    in   tuberculosis,    400; 
contraindicated  in  typhoid  fever,  278; 
in  varicella,  357;  in  urticaria,  727. 
Phimosis,     596;     association    of,     with 
enuresis,     599,     601;     association     of, 
with  pseudomasturbation,  608. 
Phosphate  of  soda.    See  Sodium  phos- 
phate. 
Phosphorus,  presence  of,  in  milk,  104; 
therapeutic    use    of,    in    rickets,    245; 
toxic  nephritis  due  to,  573,  575;  uses 
of,  to  body,  105. 
Physical   examination,   of    sick   child, 

29. 
Physical  signs,  in  aortic  regurgitation, 
501;  in  aortic  stenosis,  501;  in  ap- 
pendicitis, 224;  in  acute  bronchitis, 
240;  in  bronchopneumonia,  460;  in 
acute  cardiac  dilatation,  496;  in  fail- 
ure of  compensation,  502;  in  intesti- 
nal intussusception,  221;  in  lobar 
pneumonia,  458,  460;  in  lymph-node 
tuberculosis,  384;  in  mitral  regurgi- 
tation, 499;  in  mitral  stenosis,  501;  in 
myocarditis,  495;  in  acute  pericardi- 
tis, 510;  in  chronic  pericarditis,  514; 
in  peritonitis,  231;  in  pleurisy  with 
effusion,  472;  in  splenic  enlargement, 
551;  in  sporadic  cretinism,  553;  in 
thyroid  enlargement,  547;  in  tubercu- 
lous bronchopneumonia,  388,  462. 
Physiological  albuminuria,  567. 
Physiological  gastric    incompetency, 

158. 
Pica,  704;   treatment  of,  705. 
Pick's  disease,  514. 
"Pink  eye,"  413. 
Plasmodium  malaria,  279. 
Playgrounds,  hygienic  value  of,  10. 
Pleurisy,  470;  aspiration  for,  479;  com- 
plicating bronchopneumonia,   462;    defi- 
nition of,  470;   diet  in,  478;   displace- 
ment   of    organs   in,    475,   476 ;    drugs 
used  in  treatment   of,  478,  479;   with 
effusion,   471,   473;    etiology    of,   470; 
exploratory  puncture   in,   476;    fluoro- 


scopic examination  in,  476;  forms  of, 
471 ;  complicating  lobar  pneumonia, 
448;  microorganisms  present  in,  470; 
pain  in,  473;  pathology  of,  471;  phys- 
ical signs  in,  475;  respiration  in,  473; 
sources  of  infection  in,  470;  surgical 
treatment  of,  479;  symptomatology 
of,  472;  temperature  curve  in,  472; 
treatment  of,  472;  treatment  of,  dur- 
ing convalescence,  482;  X-ray  picture 
in,  476. 
Pneumococcus    peritonitis,    228,    231, 

232. 
Pneumococcus  vaccine,  therapeutic  use 

of,  58. 
Pneumonia,    broncho-.      See    BroncJio- 

pneumonia. 
Pneumonia,  deglutition,  462. 
Pneumonia,  food,  risk  of,  after  intuba- 
tion in  laryngeal  diphtheria,  306. 
Pneumonia,  lobar,  442;  antipyretics  in, 
451;  auscultation  in,  448;  blood 
changes  in,  447;  complications  in,  448; 
cough  in,  448;  crisis  in,  445;  danger 
from,  in  infancy,  6;  diet  in,  450;  dif- 
ferential diagnosis  in,  449;  drugs  in, 
452;  etiology  of,  442;  hygienic  treat- 
ment of,  450;  local  applications  in, 
451;  complicating  measles,  337;  medi- 
cal treatment  of,  452;  microorganisms 
present  in,  442;  mortality  from,  2, 
449;  obscure  fevers  in  infancy  due  to, 
264;  pathology  of,  443;  percussion  in, 
448;  physical  signs  in,  447;  prognosis 
of,  449;  respiration  in,  446;  sources 
of  infection  in,  443;  stimulants  in, 
451;  symptomatology  of,  444;  tem- 
perature in,  261,  444,  445;  treatment 
of,  449;  treatment  of,  during  conva- 
lescence, 453;  complicating  typhoid 
fever,  274;  urine  findings  in,  447; 
complicating  whooping-cough,  294. 
POIKILOCYTOSIS,    516. 

Poisons,  irritant,  cause  of  enterocol- 
itis, 189;  cause  of  hemoglobinuria, 
564. 

Polioencephalitis.  See  Acute  anterior 
poliomyelitis. 

Poliomyelitis,  acute  anterior,  641; 
abortive  type,  645;  ataxic  type,  646; 
bulbar  type,  645;  chronic  changes  in, 
644;  definition  of,  641;  descending 
type  of,  645;  diagnosis  of,  649;  elec- 
trical reactions  in,  649 ;  encephalitic 
type,  646;  epidemic  form  of,  642;  eti- 
ology of,  641;  immunity  from,  644; 
meningeal  type,  646;  mortality  from, 
650;  muscular  atrophy  in,  648;  paral- 


INDEX 


771 


ysis  in,  647;  pathology  of,  643;  poly- 
neuritic type,  647;  pontine  type,  645; 
prophylaxis  of,  651;  prognosis  of,  650; 
sources  of  infection  in,  642;  spinal 
poliomyelitic  type,  646;  sporadic  form 
of,  642;  symptomatology  of,  644: 
transmission  of,  641 ;  treatment  of, 
651;  treatment  of  paralysis  in,  652; 
use  of  urotropin  in,  651. 

polychromasia,  516. 

Polycythemia,  516. 

Polypnea  in  young  children,  27. 

Polypus  of  the  rectum,  234. 

Porter,  W.  T.,  on  comparative  rate  of 
growth  in  children  at  public  schools, 
16;  on  physical  basis  of  precocity  and 
dullness,  7. 

Porter  and  Fleischner,  report  of  re- 
current vomiting  associated  with  cysto- 
pyelitis,  585. 

Position,  significance  of,  in  examination 
of  sick  child,  30. 

Postural  albuminuria.  See  Orthosta- 
tic albuminuria. 

Postnatal  palsies,  611. 

Potassium  acetate,  therapeutic  use  of, 
in  pleurisy  with  effusion,  478. 

Potassium  bicarbonate,  therapeutic  use 
of,  in  enuresis,  602. 

Potassium  carbonate,  therapeutic  use 
of,  in  urethritis  in  male  child,  596. 

Potassium  chlorate,  hemoglobinuria 
caused  by,  564;  hematuria  caused  by, 
563;  purpura  caused  by,  532;  thera- 
peutic use  of,  in  stomatitis  ulcerosa, 
151;  toxic  nephritis  caused  by,  573, 
575. 

Potassium  citrate,  therapeutic  use  of, 
in  cystopyelitis,  586. 

Potassium  iodid,  therapeutic  use  of,  in 
brain  tumors,  617;  in  hydrocephalus, 
620. 

Potassium  permanganate,  therapeutic 
use  of,  in  gonococcus  vulvovaginitis, 
594. 

Pott's  disease,  391;  examination  for, 
31;  myelitis  as  complication  of,  653, 
654,  655,   656. 

Poverty,  tuberculosis  a  cause  of,  375. 

PoYNTON,  on  presystolic  murmur  in  mi- 
tral  regurgitation,   500. 

Premature  infants,  62;  artificial  feed- 
ing for,  68;  breast  feeding  for,  67; 
digestive  system  in,  64;  feeding  of, 
67;  heat-regulating  mechanism,  25,  62; 
hereditary  disease  in,  64;  incubator 
for,  66;  nervous  system  in,  62;  pad- 
ded basket  for,  66;  physical  peculiari- 


ties of,  62;  prognosis  for,  65;  quanti- 
ty of  food  for,  68;  susceptibility  to 
reinfection  in,  64;  treatment  of,  65; 
weight  of,  65;   wet  nurse  for,  68. 

Prenatal  palsies,  610. 

Prepuce,  adherent,  596;  enuresis  asso- 
ciated with,  599,  601;  pseudomastur- 
bation  associated  with,  608. 

Pressure  signs  in  lymphnode  tuber- 
culosis, 385. 

Priessnitz's  application,  in  treatment 
of  bronchopneumonia,  468;  in  treat- 
ment of  lobar  pneumonia,  451. 

Proctitis,  236. 

Prolapse  of  rectum,  234. 

Progressive  muscular  dystrophy,  666; 
definition  of,  666;  Erb's  juvenile  type 
of,  668;  etiology  of,  666;  Landouzy- 
Dejerine  type  of,  668;  peroneal  type 
of,  668;  pseudohypertrophic  type  of, 
666;  symptomatology  of,  666;  treat- 
ment of,  669. 

Proprietary  foods,  127;  in  causation  of 
rickets,  237;  in  causation  of  scurvy, 
246;  value  of,  in  artificial  feeding, 
127;  value  of,  in  chronic  gastritis, 
172;  value  of,  in  hot  weather,  182; 
value  of,  in  typhoid  fever,  277. 

Protein,  digestibility  of,  135;  indiges- 
tion from,  186;  nutritional  value  of, 
103;  proportion  of,  in  beef  juice,  129; 
proportion  of,  in  broth,  129;  propor- 
tion of,  in  buttermilk,  122,  123;  pro- 
portion of,  in  Finkelstein 's  albumin 
milk,  123;  proportion  of,  in  malt 
soups,  124;  proportion  of,  in  nulk, 
101;  proportion  of,  in  skimmed  milk, 
124. 

Proteus  vulgaris,  in  causation  of  en- 
teric infection,  178. 

Pryor,  on  development  of  bony  frame- 
work in  child,  19. 

Pseudo-diphtheritic  bacillus,  in  caus- 
ation of  simple  vulvovaginitis,  595. 

Pseudo-hypertrophic  form  of  progres- 
sive muscular  dystrophy,  666. 

Pseudoleukemia  of  infants,  524;  age 
as  predisposing  factor  in,  524;  blood 
changes  in,  525;  definition  of,  524; 
diet  in,  526;  differential  diagnosis  in, 
525;  drugs  used  in  treatment  of,  526; 
etiology  of,  524;  prognosis  of,  526; 
symptomatology  of,  525;  temperature 
curve  in,  525;   treatment  of,  526. 

PsEUDOMASTURBATiON,  603;  age  as  etio- 
logical factor  in,  604;  definition  of, 
603;  direct  causes  of,  607;  drugs  used 
in  treatment  of,  609;   environment  as 


772 


INDEX 


etiological  factor,  606;  epilepsy  not 
related  to,  607;  etiology  of,  604; 
general  treatment  of,  609 ;  habit  as 
etiological  factor  in,  606;  mechanical 
treatment  of,  609;  neurotic  inheri- 
tance an  etiological  factor  in,  606; 
prognosis  of,  607;  sex  as  an  etiologi- 
cal factor  in,  606;  symptomatology 
of,   603;   treatment  of,   607. 

Psychic  kpilepsy,  693. 

Psychotherapy,  value  of,  in  nervous 
disorders,  54;  in  whooping-cough, 
292. 

Puberty,  rapid  growth  in  height  pre- 
ceding, 17;  rapid  growth  in  weight 
preceding,  16;  reflex  disturbances  at, 
13;  thyroid  gland  excessively  active 
at,  17. 

Public  school  system,  hygienic  defects 
in,  8. 

Pulmonary  tuberculosis.  See  Tuber- 
culosis of  the  lungs  under  Tuberculosis. 

Pulse  rate,  instability  of,  in  infancy, 
484;  peculiarities  of,  in  myocarditis, 
495;  peculiarities  of,  in  typhoid  fe- 
ver, 270;  rapidity  of,  in  bronchopneu- 
monia, 457;  rapidity  of,  in  pleurisy, 
with  displacement  of  the  heart  from 
effusion,  473;  ratio  between,  and  tem- 
perature in  lobar  pneumonia,  444. 

Puncture,  exploratory,  in  pleurisy 
with   effusion,  476. 

Puncture,  lumbar.    See  Lumbar. 

Purpura,  531 ;  character  of  eruption  in, 
531;  definition  of,  531;  diet  in,  535; 
drugs  in  causation  of,  532;  drugs 
used  in  treatment  of,  536;  etiology  of, 
532;  fulminans,  523,  537;  hemorrha- 
gica,   533,    536;     Henoch's     purpura, 

534,  537;  hydrotherapy  for,  536;  med- 
ical   treatment    of,    536;    rheumatica, 

535,  537;  simplex,  532;  symptomatica, 
532;  temperature  curve  in  p.  hemor- 
rhagica, 533 ;  treatment  of,  535 ;  treat- 
ment of  special  forms,  536;  varieties 
of,  532. 

"Purpuras,"  531, 

Purulent  meningitis.  See  Meningitis, 
purulent. 

Putnam,  on  arsenic  as  cause  of  neuritis 
in  children,  661 ;  on  night  terror,  673, 
675. 

Pyelitis,  diagnosis  between,  and  ma- 
laria, 284.    - 

Pyemia,  diagnosis  between,  and  malaria, 
284. 

Pyelocystitis,  as  cause  of  obscure  fever 
in  infancy,   264. 


Pyramidon,  therapeutic  use  of,  in  fever 
of  tuberculosis,  400. 


Q 


Quarantine,  hygienic  reasons  for,  6; 
length  of,  in  diphtheria,  302;  in  influ- 
enza, 312;  in  measles,  339;  in  mumps, 
358;  in  acute  anterior  poliomyelitis, 
651;  in  rubella,  343;  in  scarlet  fever, 
327;  in  varicella,  357;  in  variola,  348; 
in  whooping-cough,  288. 

Quassia,  use  of,  for  removal  of  oxyuris 
vermicularis,  218. 

QuiNiN,  therapeutic  use  of,  in  asthma, 
713;  in  chlorosis,  528;  in  chorea,  701; 
in  headache,  710;  in  influenza,  313; 
in  lobar  pneumonia,  452;  in  malaria, 
284;  in  rhinitis,  415;  in  tonsillitis, 
422;  in  whooping-cough,  293;  purpura 
caused  by,  532. 

Quinsy.     See  Peritonsillar  abscess. 


E 


Eachitis.     See  EicTcets, 

Eadial  fissures,  364,  355. 

Eadiography.     See  X-Ray  treatment. 

Eansohoff's  method  for  after-treatment 
of  empyema,  48. 

"Easpberry  excrescence,"  353. 

Eeactions,  electrical,  in  facial  paraly- 
sis, 665 ;  in  multiple  neuritis,  663 ;  in 
acute  anterior  poliomyelitis,  649 ;  in 
progressive  muscular  dystrophy,  667. 

Eectal  enemata,  therapeutic  value  of, 
51. 

Eectal  feeding,  therapeutic  value  of, 
51. 

Eectal  irrigation,  therapeutic  value  of, 
46. 

Eectal  suppositories,  therapeutic  value 
of,  52;  in  constipation,  207;  in  scar- 
let fever,  331;  in  typhoid  fever,  278; 
objections  to,  in  artificially  fed  in- 
fant,  206. 

Eectal  temperature,  importance  of 
taking,  in  examination  of  sick  child, 
29. 

Eectum,  malformation  op.  See  Mal- 
formation. 

Eectum,  polypus  of,  234. 

Eectum,  prolapse  of,  234;  in  enteric 
infection,  191;  caused  by  whooping- 
cough,  289. 

Eecurrent  coryza,  258. 

Eecurrent  vomiting,  251;  blood 
changes  in,  254;  climate  in  treatment 


INDEX 


773 


of,  257;  clinical  types  of,  254;  in 
cystopyelitis,  285;  definition  of,  251; 
diagnosis  of,  254;  diet  in,  254;  drugs 
used  in  treatment  of,  255,  256;  etiol- 
ogy of,  251;  exciting  causes  of,  251; 
hygiene  in  treatment  of,  257;  pain  in, 
253;  predisposing  causes  of,  252; 
prognosis  of,  254;  symptomatology 
of,  252;  synonyms  for,  251;  tempera- 
ture changes  in,  253;  treatment  of  at- 
tack of,  255;  treatment  of  interval  in, 
256;  urine  findings  in,  254. 

Red  light  treatment  of  small-pox, 
349. 

Eeflex  centers,  imperfect  development 
of,  in  premature  infants,  64. 

Eeflex  irritation,  development  of  geni- 
tal organs  a  cause  of,  13;  eclampsia 
due  to,  668;  eczema  due  to,  719,  722; 
enuresis  due  to,  601 ;  epilepsy  due  to, 
692,  695;  headache  due  to,  709;  habit 
spasm  due  to,  702;  hysteria  due  to, 
705;  insomnia  due  to,  676;  laryngis- 
mus stridulus  due  to,  684;  masturba- 
tion due  to,  606,  608;  nervous  strain 
due  to,  10,  11,  13;  night-terror  due  to, 
772;  tetany  due  to,  687. 

Reflexes,  examination  of,  in  sick  child,' 
31;  in  acute  anterior  poliomyelitis, 
644;  in  progressive  muscular  dystro- 
phy, 607. 

Renal  calculi,  formation  of,  in  in- 
fants, 562. 

Resobcin,  therapeutic  use  of,  in  ec- 
zema, 723. 

Respiration,  acceleration  of,  for  slight 
causes  in  infancy,  110;  artificial,  72; 
peculiarities  of,  in  child,  410. 

Respiratory  centers,  imperfect  devel- 
opment of,   in  premature  infants,  63. 

Respiratory  movements,  examination 
of,  in  sick  child,  30. 

Rest,  therapeutic  value  of,  52;  in  acute 
articular  rheumatism,  405;  in  chorea, 
700;  in  control  of  fever  in  tubercu- 
losis, 400;  in  eclampsia,  684;  in  endo- 
carditis, 495;  in  infancy,  11,  13,  135; 
in  hysteria,  768 ;  in  myocarditis,  498 ; 
in  new-born,  4 ;  in  pericarditis,  535 ; 
in  acute  anterior  poliomyelitis,  651; 
in  tuberculous  peritonitis,  401;  in  val- 
vular heart  disease,  505. 
Rest  in  bed,  therapeutic  value  of,  in 
acute  nephritis,  580;  in  multiple  neu- 
ritis, 663;  contraindieated  in  ortho- 
static albuminuria,  570. 
Rest  cure,  indications  for,  52. 
Retro-phabyngeal  abscess,  427;   diag- 


nosis of,  428;  microorganisms  present 
in,  427;  predisposing  causes  of,  428; 
prognosis  of,  429;  sources  of  infection 
in,  427;  symptomatology  of,  428;  tem- 
perature changes  in,  428;  treatment 
of,  429. 

Reuss,  experiments  by,  on  value  of  dex- 
tri-maltose  preparations,  125. 

Rheumatic  nodules,  403. 

Rheumatic  wry  neck,  403. 

Rheumatism,  acute  articular,  402; 
chorea  due  to,  404,  697;  definition  of, 
402;  diagnosis  of,  404;  diet  in  attack 
of,  405;  diet  in  interval  of,  406;  drugs 
used  in  treatment  of,  405;  erythema 
multiforme  due  to,  729;  etiological 
factor  in  endocarditis,  489;  etiology 
of,  402;  heart  disturbances  in,  404; 
heredity  in  causation  of,  402;  medical 
treatment  of,  405;  microorganisms 
present  in,  402;  myelitis  as  sequel  to, 
653;  prognosis  of,  405;  salicylates  in 
the  treatment  of,  405;  simple  anemia 
in,  404;  sources  of  infection  in,  402; 
symptomatology  of,  403;  temperature 
changes  in,  405;  tonsillitis  in,  404; 
treatment  of  attack,  405;  treatment 
of  interval,  406;  valvular  heart  dis- 
ease due  to,  498,  503. 

Rheumatism,  scarlatinal,  324,  331. 

Rhinitis,  acute,  411;  adenoid  disease  a 
cause  of,  425;  definition  of,  411;  drugs 
used  in  treatment  of,  415;  etiology  of, 
411;  acute  laryngitis  following,  430; 
microorganisms  present  in,  411;  proph- 
ylaxis in,  414;  prognosis  of,  413; 
sources  of  infection  in,  411;  sympto- 
matology of,  412;  temperature  changes 
in,  412,  413;  treatment  of,  414. 

Rhinitis,  chronic,  414;  treatment  of, 
415. 

Rickets,  237;  blood  changes  in,  242; 
bony  deformities  in,  241;  congenital 
form,  242;  course  of,  242;  curative 
treatment  of,  243;  definition  of,  237; 
diagnosis  of,  242;  drugs  used  in  treat- 
ment of,  244;  eclampsia  caused  by, 
679;  gastrointestinal  disorders  in,  240; 
head-sweating  in,  240;  hernia  in,  240; 
general  appearance  in,  239 ;  late  form, 
412;  morbid  anatomy  of,  238;  previous 
symptoms  in,  240;  pathology  of,  238; 
prevention  of  deformities  in,  245; 
prognosis  in,  242;  prophylaxis  in,  243; 
symptomatology  of,  239;  treatment  of, 
243;  treatment  of  deformities  in,  245; 
tetany  caused  by,  686;  weakness  of 
ligaments  and  muscles  due  to,  240. 


774 


INDEX 


Ringworm  op  the  tongue.  See  Geo- 
graphical toiKjue. 

Roger,  on  situation  of  systolic  murmur 
in  defective  interventricular  septum, 
487. 

Romberg  and  Passler,  on  splanchno- 
paralysis  as  a  result  of  pneumococcus 
toxins,  448. 

Romberg's  sign,  657. 

Rontgen  rays,  diagnostic  value  of,  38; 
in  bone  and  muscle  development  and 
capacity,  19,  20;  in  bone  and  joint 
tuberculosis,  393;  in  congenital  dilata- 
tion of  the  colon,  209;  in  cystopyelitis, 
586;  in  demonstration  of  enlarged  thy- 
mus, 547;  in  foreign  bodies  in  larynx, 
trachea,  and  bronchi,  437;  in  infective 
arthritis,  408;  in  lymph  node  tubercu- 
losis, 385;  in  acute  pericarditis,  511; 
in  pleurisy  with  effusion,  476;  in  per- 
sistent patulous  ductus  arteriosus,  488; 
in  spina  bifida,  659;  in  status  lym- 
phaticus,  547. 

Rontgen  rays,  therapeutic  value  of,  in 
Hodgkin's  disease,  542;  in  leukemia, 
531;  in  status  lymphaticus,  548,  549; 
in  tinea  tonsurans,  735;  in  thyroid  en- 
largement, 549;  rules  for  use  of,  in 
status  lymphaticus,  550;  technique  for 
vrse  of,  in  thyroid  enlargement,  549. 

Rose  position,  in  operation  for  retro- 
pharyngeal abscess,  429. 

Rose  spots,  in  diagnosis  of  typhoid  fe- 
ver, 271. 

Rotch,  on  increase  in  height  during  first 
month  of  life,  17;   on  indications  for 
paracentesis  in  acute  pericarditis,  513; 
on  lack  of  conformity  between  chrono- 
logical age   and  physical  development, 
20;  on  modification  of  milk,  141;  prac- 
tical system  by,  for  grading  work  of 
child,   20;    on  relative  frequency  with 
which     tuberculosis    attacks     different 
joints,  381;  report  by,  on  case  of  men- 
ingococcie    meningitis    in    infant    six 
days   old,    631;    on   Rontgenization   of 
wrist  bones  as  indication  of  bone  and 
muscle    development   in   child,    19;    on 
structure  of  spine  at  birth,  19. 
Rotch  laboratory  method  of  modify- 
ing MILK,  141. 
Rotheln.     See  Eubella. 
Round  worm.    See  Ascaris  lurribrieoides. 
Roux,  work  done  by,  upon  antitoxin,  302. 
Rubella,   341;    blood    changes   in,   343; 
complications    in,    343 ;    definition    of, 
341 ;  drugs  used  in  treatment  of,  343 ; 
enanthem   of,    342;    etiology   of,   341; 


exanthem  of,  342;  immunity  from, 
341;  incubation  period  in,  341;  lym- 
phatic tissue  affected  in,  342;  progno- 
sis of,  343;  symptomatology  of,  341; 
temperature  changes  in,  341 ;  treatment 
of,  343;  urine  findings  in,  343. 
Rurah,  table  by,  showing  causes  of  noc- 
turnal enuresis,  600;  table  by,  show- 
ing differential  diagnosis  of  acute  ex- 
anthemata, 344. 

S 

Saboueaxtd,  on  the  parasite  causing  tinea 
tonsurans,  733. 

Sachs,  on  aphasia  associated  with  left- 
sided  hemiplegia,  613;  on  epilepsy, 
692,  694;  on  relation  of  epilepsy  to 
early  spastic  palsies,  613;  on  surgical 
treatment  of  epilepsies,  696;  table  by, 
showing  classification  of  infantile  cere- 
bral palsies,  611. 

Salicylate  of  sodium,  therapeutic  value 
of,  in  facial  paralysis,  666;  in  acute 
follicular  tonsillitis,  422. 

Salicylates,  diagnostic  value  of,  in 
rheumatism,  404;  therapeutic  value  of, 
in     acute     endocarditis,     complicating 

■  rheumatism,  493 ;  in  pleurisy,  with 
gout  tendencies,  478;  in  prophylaxis 
of  endocarditis,  493 ;  in  rheumatism, 
405;  in  valvular  heart  disease  due  to 
rheumatism,  504. 

Salicylic  acid  ointment,  therapeutic 
use  of,  42,  43;  in  congenital  ichthyosis, 
731;  in  eczema,  723;  in  impetigo  con- 
tagiosa, 732;  in  pleurisy,  479;  in  tinea 
tonsurans,   734. 

Salol,  therapeutic  use  of,  in  acute  ca- 
tarrhal bronchitis,  441;  in  chlorosis, 
528;  in  chorea,  701;  in  cystopyelitis, 
587;  in  acute  endocarditis,  494;  in  in- 
fluenza, 314;  in  pernicious  anemia, 
529;  in  pseudoleukemia,  526;  in  tonsil- 
litis, 422;  in  typhoid  fever,  277;  in 
urethritis  in  male  child,  596;  in  urti- 
caria, 728. 

Salt  baths,  therapeutic  value  of,  46. 

Salvarsan,  therapeutic  use  of,  in  syphi- 
lis, 372. 

Santonin,  therapeutic  use  of,  for  ascaris 
lumbricoides,  216;  for  oxyuris  vermi- 
cularis,  218. 

Scabies,  735;  treatment  of,  736. 

Scarlet  fever,  315;  antistreptococcic  se- 
rum in,  330;  cervical  adenitis  in,  321; 
climatic  influences  upon,  315;  compli- 
cations in,  324;  contagious  period  in, 
317;    convalescence  from,  332;    defini- 


INDEX 


tion    of,    315;    desquamation   in,   322- 
diagnosis  of,  325;   tliet  in,  329;   drugs 
used  in  treatment  of,  330;  eruption  in, 
321,    325;    etiology   of,    315;    exciting 
causes   of,   316;    fulminating   type   of, 
323;  geographical  distribution  of,  316;' 
hydrotherapy   in,   329;    incubation   pe- 
riod in,  318;   inunctions  in,  330,  331; 
irregular   clinical    types   of,   323;    ma- 
lignant type  of,  323;   measles  compli- 
cated by,  338;  microorganism  in,  316; 
mild  type  of,  323;   mortality  from,  2, 
325;    mycotic    nephritis   due    to,    574; 
pathology  of,  317;  predisposing  causes 
of,    315;    prognosis    of,    325;    prophy- 
laxis of,  327;   quarantine  in,  327;   re- 
currence of,  323;  relapses  in,  323;  sep- 
tic type  of,  323;   sore  throat  in,  321; 
sources    of    infection    in,    316;    stimu- 
lants in,  329;  symptomatology  of,  318; 
temperature   changes   in,   318;    tongue 
in,   321;    transmission   of,   316;    treat- 
ment of,  328;   treatment  of  nose  and 
throat  in,  330;  urine  findings  in,  322; 
vomiting  in,  318. 
Scarlatina.    See  Scarlet  fever. 
ScHONLEiN  's  DISEASE.  See  Purpura  rheu- 

matiea. 
School  work,  nervous  strain  of,  8;  habit 
spasm  due  to,  702;  hysteria  due  to, 
705;  insomnia  due  to,  676;  night-ter- 
ror due  to,  672;  weight  a  test  of  en- 
durance of,  7,  8. 

SCHOTTMUELLER 'S  DISEASE,   494. 

Schultze's  METHOD  of  artificial  respira- 
tion, 72. 

Scorbutus.    See  Scurvy. 

Scurvy,  infantile.     See  Infantile. 

Seborrhea,  character  of,  720;  treatment 
of,  726. 

Seibert,  on  humidity  affecting  mortality 
from  intestinal  disorders,  180;  on  ich- 
thyol  ointment  in  scarlet  fever,  330. 

Septicemia,  complicating  diphtheria,  299, 
307;  complicating  scarlet  fever,  323, 
330;  diagnosis  between,  and  malaria, 
284. 

Septic  arthritis,  as  a  complication  in 
scarlet  fever,  324. 

Septic  infection.    See  Sepsis. 

Sepsis,  diphtheria  complicated  by,  296; 
fever  in  second  week  of  life  due  to, 
263;  myelitis  following,  655;  obscure 
fevers  in  childhood  due  to,  265;  pre- 
mature infants  liable  to,  164. 
Septic  infections  in  new-born,  75; 
diagnosis  of,  78;  etiology  of,  75;  in- 
dividual  symptoms   in,    78;    prognosis 


775 


in,    79;    sources   of   infection    in,    76; 

symptomatology  of,   77. 
Serum,  antimeningitic,  636;   effect  of, 

upon   prognosis,   635;   effect   of,  upon 

sequela;,  635 ;  nature  of,  60. 
Serum,    antistreptococcic,    therapeutic 

use  of,  in  diphtheritic  septicemia,  307; 

in  hemophilia,  540;   in  acute  infective 

myelitis,   657;    in  measles   with  septic 

complications,    340;    in    scarlet    fever, 

330;  in  stomatitis  gangrenosa,  153;  in 

ulcerative  endocarditis,  494. 
Serum,  antitoxin,  of  diphtheria.    See 

Antitoxin. 
Serum,    standardized    animal    blood, 

therapeutic     use     of,     in     hemophilia, 

540.  ' 

Serum    treatment,    59;    asthmatic    pa- 
tients unsuited  for,  713;  in  diphtheria, 
302,  307;  in  hemophilia,  540;  in  acute 
infective  myelitis,  657;  in  measles  with 
septic  complications,  340;   in  meningo- 
coccic    meningitis,    635;    rashes    from, 
mistaken    for    scarlet    fever,    330;    in 
scarlet  fever,  330;   in  stomatitis  gan- 
grenosa,   153;    in   ulcerative    endocar- 
ditis, 494. 
Shell-pish,  a  source  of  infection  in  ty- 
phoid fever,  268,  275, 
Shiga  bacillus,  association  of,  with  gas- 
troenteric affections,  178. 
SiLBERMANN,    On   types    of    night-terror, 

672,  673,  674. 
Sight,  sense  of,  in  infancy,  22. 
Silver  nitrate,  therapeutic   use   of,   in 
local  treatment  of  scarlet  fever,  330; 
by  irrigation,  in  cystopyelitis,  587;  in 
gonococcus  vulvovaginitis,  594. 
Silver,  colloidal,  therapeutic  use  of,  43. 
Simple  secondary  anemla,  522. 
Skimmed  milk,  124. 
Skin  reactions  from  tuberculin.     See 

Tuberculin. 
Skin,  inspection  of,  in  illness,  30;  itch- 
ing   of,    in    status    lymphaticus,    547; 
stimulation  of,  in  acute  nephritis,  579. 
Sleep,  amount  of,  necessary  in  childhood, 
671;    amount    of,    necessary    to    new- 
born, 4 ;  amount  of,  necessary  to  school 
child,    13;    disorders    of,    669;    physi- 
ology of,  669. 
Sleep,  disorders  of,  669;  insomnia,  675; 
night-terrors,    672;     pavor    noctumus, 
671;   somnambulism,  677. 
Small-pox.     See   Variola. 
Smith,    Eustace,    on    venous    hum    in 
fiuctional  heart  disease,  508;   on  ve- 


776 


INDEX 


nous  hum  in  tuberculosis  of  lymph- 
nodes,  384. 

Snake  venom,  a  cause  of  purpura,  532. 

Snow,  on  intestinal  intussusception,  220. 

"Snuffles,"    363. 

Sodium  benzoate,  rherapeutic  use  of,  in 
acetonuria,  567;  in  enuresis,  602;  in 
influenza,  313;  in  pseudomasturba- 
tion,  609;  in  valvular  heart  disease, 
504. 

Sodium  bicarbonate,  therapeutic  use  of, 
567;  in  artificial  feeding,  139;  in  cys- 
topyelitis,  586;  in  eczema,  722;  in  en- 
docarditis, 494;  in  enuresis,  602;  in 
pica,  705;  in  recurrent  vomiting,  256; 
in  rheumatism,  405,  406,  407;  in  urti- 
caria, 727;  in  valvular  heart  disease 
due  to  rheumatism,   504. 

Sodium  chlorid,  therapeutic  use  of,  in 
artificial  feeding,  139 ;  in  hemoglobinu- 
ria, 565. 

Sodium  citrate,  use  of,  in  artificial 
feeding,   139. 

Sodium  phosphate,  therapeutic  use  of, 
in  eczema,  722;  in  enuresis  associated 
with  constipation,  603;  in  purpura, 
536. 

Sodium  salicylate,  therapeutic  use  of, 
in  chorea,  701;  in  facial  paralysis, 
666;  in  pleurisy,  478;  in  tonsillitis, 
422;  in  urticaria,  728;  in  valvular 
heart  disease  due  to  rheumatism,  505. 

Sodium  sulphate,  therapeutic  use  of, 
in  enuresis  associated  with  constipation. 
603;  in  purpura,  536. 

Somnambulism,  677;  treatment  of,  678. 

SOPER,  on  use  of  abdominal  belt  in 
whooping-cough,   293. 

Southworth,  on  food  percentages,  139. 

"Soxhlet's  Nahrzucker,"  125. 

Spasm  op  anus,  236. 

Spasmophilic  diathesis,  687. 

Spanish-American  Commission,  on  in- 
cubation period  in  typhoid  fever,  269. 

Special  senses,  development  of,  22. 

Speech,  development  of  function  of,  22. 

Spiegelbubg,  on  food  consumption  in 
infants,   130. 

Spina  bifida,  658;  definition  of,  658; 
diagnosis  of,  660;  meningocele  form 
of,  658;  meningomyelocele  form  of, 
659;  prognosis  of,  660;  syringomyelo- 
cele form  of,  660;   treatment  of,  660. 

Spinal  column,  examination  of,  in  sick 
child,  31. 

Spinal  cord,  diseases  of,  641. 

Spine  and  bony  framework,  develop- 
ment of,  19. 


Spine,  curvature  of,  in  school  child,  19. 
gymnastic  exercises  in  correction  of, 
53. 

Spleen,  diseases  of,  551,  552. 

Spleen,  enlargement  of,  551;  in  ane- 
mias, 522;  causes  of,  552;  clinical 
significance  of,  552;  diagnosis  of, 
551;  disorders  of  malnutrition  associ- 
ated with,  552;  in  Hodgkin 's  disease, 
541;  in  acute  infectious  diseases,  552; 
in  leukemia,  531;  in  malaria,  282;  in 
mumps,  359;  physical  signs  of,  551; 
in  acute  anterior  poliomyelitis,  646; 
in  pseudoleukemia,  525;  in  status 
lymphaticus,  545,  547;  in  syphilis, 
362,  366,  367;  in  tuberculosis  of  mes- 
enteric lymph  nodes,  383;  in  typhoid 
fever,  271. 

Splenocytes.  See  Mononuclear  leuko- 
cytes. 

Splenomegaly,  552. 

Spolverini,  on  development  of  amylase, 
105;  on  digestive  ferments  present  in 
milk,  107. 

Sporadic  cretinism.     See  Cretinism. 

Sprue.     See  Stomatitis  mycosa. 

Squills,  objections  to  use  of,  in  bron- 
chopneumonia, 467;  in  acute  catarrhal 
bronchitis,  441;  in  lobar  pneumonia, 
453. 

Staphylococcus  vaccine,  therapeutic 
use.  of,  57. 

Starr,  table  by,  showing  nature  and  po- 
sition of  brain  tumors,  616. 

St.  Anthony's  dance.     See  Chorea. 

Starten's  lotion,  723. 

Status  lymphaticus,  545;  anatomy  of, 
545;  anesthesia  dangerous  in,  547; 
blood  changes  in,  547;  definition  of, 
545;  diet  in,  550;  drugs  used  in  treat- 
ment of,  550;  dyspepsia  in,  546;  ex- 
ercise in,  550;  fresh  air  in,  550;  mor- 
tality in,  548 ;  pathology  of,  545 ;  prog- 
nosis of,  548;  Rontgen  rays  in  diag- 
nosis of,  547;  Rontgen  rays  in  treat- 
ment of,  548;  sudden  death  in,  546; 
surgical  treatment  of,  550;  sympto- 
matology of,  546;  thymic  asthma  in, 
.546;  thymic  enlargement  in,  547; 
treatment  of,  548. 

Steel,  operation  by,  for  obstruction  of 
esophagus,  158. 

Sterilized  milk,  119. 

Sterility,  due  to  gonococcus  vulvova- 
ginitis  in   infancy,   593. 

Still,  on  orthostatic  albuminuria,  569, 
570. 


INDEX 


r77 


Still  's  disease.    See  Chronic  rheumatoid 

arthritis. 
Stock  vaccines,  therapeutic  use  of,  57. 
Stools,  character  of,  in  enteric  infection, 
191;   in  fat  indigestion,  185;  in  acute 
intestinal  indigestion,   184;    in  protein 
indigestion,   186;  in  sugar  indigestion, 
186;  therapeutic  value  of  examination 
of,  in  illness,  34. 
Stomach,  diseases  of,  158. 
Stomach  washing.    See  Lavage. 
Stomatitis    aphthosa,    147;    complicat- 
ing measles,  338;   treatment  of,  148. 
Stomatitis  catakkhalis,  146;  treatment 

of,  147. 
Stomatitis     gangrenosa,     152;     treat 

ment  of,   153. 
Stomatitis  mycosa,  148;   treatment  of, 

149. 
Stomatitis    ulcerosa,    150;    treatment 

of,  151. 
Stramonium,  inhalation  of,  in  treatment 

of  asthma,  712. 
Strapping  chest,  for  relief  of  pain  in 

pleurisy,   478. 
"Strawberry  tongue,"  321. 
Streptococcus  enteritides,  as  cause  of 

enteric  infection,  178. 
Streptococcus  vaccine,  therapeutic  use 

of,  58. 
Strophanthus,  therapeutic  use  of,  in 
bronchopneumonia,  466;  in  acute  car- 
diac dilatation,  498;  in  diphtheria, 
307;  in  acute  endocarditis,  494;  in 
intestinal  hemorrhage  of  typhoid  fever, 
278;  in  lobar  pneumonia,  452;  in  mea- 
sles, 340;  in  meningococcic  meningi- 
tis, 638;  in  pleurisy,  with  effusion, 
478;  in  scarlet  fever,  330;  in  valvular 
heart  disease,  505;  in  variola,  349;  in 
whooping  cough,  294. 
Strychnin,  therapeutic  use  of,  in  as- 
phyxia neonatorum,  73;  in  broncho- 
pneumonia, 406;  in  constipation,  208; 
in  acute  cardiac  dilatation,  498;  in 
diphtheria,  307;  in  enuresis,  603;  in 
multiple  neuritis,  664;  in  acute  peri- 
carditis, 513;  in  acute  anterior  polio- 
myelitis, 651;  in  scarlet  fever,  330;  in 
valvular  disease  of  the  heart,  505. 
St.  Vitus'  dance.  See  Chorea. 
Sugar,  acid  fermentation,  due  to,  in 
food,  125;  indigestion  due  to  excess 
of,  135,  186;  proportion  of,  in  butter- 
milk, 122,  123;  proportion  of,  in 
Finkelstein 's  milk,  123;  proportion  of, 
in  milk,  103 ;  proportion  of,  in  skimmed 
milk,  124. 


Suggestion,  therapeutic  use  of,  in  epi- 
lepsy, 695;   in   hysteria,   708. 
Sulphate    of    soda.      See   Sodium    sul- 
phate. 
Sulphur  ointment,  therapeutic  use  of, 
in   congenital   ichthyosis,   731;    in   im- 
petigo contagiosa,  732;  in  scabies,  736; 
in    tinea   tonsurans,    733;    in   tubercu- 
losis,  729. 
"Summer  complaint,"  180. 
Suppositories,  rectal.    See  Bectal  sup- 
positories. 
Svehla,  on  theory  as  to  cause  of  status 

lymphaticus,  545,  546. 
Sydenham  's  chorea.     See  Chorea. 
Syphilis,  360;    acquired   form   of,  360, 
361;  blood  changes  in,  366;  bones  af- 
fected by,  360,  361;  brain  affected  by, 
366;    brain   tumor  due   to,   617;   com- 
parative  value   of   mercurial   prepara- 
tions in  treatment  of,  371;  congenital 
form    of,    360,    361;    coryza    in,    363; 
deafness     from,     367;     definition     of, 
360;    diagnosis  of,  367;   diet  in,  369; 
drugs  used  in  treatment  of,  370;   eti- 
ology of,  361;  general  malnutrition  in, 
365,    367;    gummatous    ulcerations   in, 
367;    hydrocephalus  due  to,  619,  620; 
interstitial  keratitis  due  to,  367;  iodin 
in  treatment  of,  371;  kidneys  affected 
by,  366;  laryngismus  stridulus  due  to, 
685;   late  hereditary  form  of,  366;  lo- 
cal treatment  of,  373;   medical  treat- 
ment  of,   370;    mercury  internally   in, 
370;  mercury  by  inunction,  370;  meth- 
od of  obtaining  blood  for  examination 
in,  368;  microorganism  in,  360;  myeli- 
tis due  to,  655;  in  new  born,  83,  364; 
nose  and  throat  affected   by,  367;    in 
nursing    infants,    112;    pathology    of, 
362;  a  predisposing  cause  of  malaria, 
594;    prognosis    of,    368;    prophylaxis 
of,    369;    salvarsan    in    treatment    of, 
372;  skin  lesions  in,  364,  367;  spleen 
affected  by,  366,  367;  symptomatology 
of,   362;    teeth   affected   by,   46,   365; 
transmission   of,    361,    362;    treatment 
of,   369;    vaccination  not  a   means   of 
transmission,    353;    Wassermann    reac- 
tion in  diagnosis  of,  368. 
Syringomyelocele,  660. 
Syrup    of    hydriodic    acid,    therapeutic 
use    of,    in    asthma,    713;    in    chronic 
bronchitis,  442;  in  convalescence  from 
bronchopneumonia,    469;    in    convales- 
cence  from   acute   laryngitis,   433;    in 
convalescence   from    lobar  pneumonia, 
453. 


778 


INDEX 


Syrup  of  iodid  of  ikon,  therapeutic  use 
of,  iu  tuberculosis,  399. 

Syrup  of  ipecac,  therapeutic  use  of, 
in  asthma,  712;  in  acute  catarrhal 
bronchitis,  441;  in  acute  laryngitis, 
432;  contraindicated,  in  bronchopneu- 
monia, 467;   in  lobar  pneumonia,  453. 

Systemic  intoxication,  a  cause  of  ob- 
scure fever  in  infancy,  261,  262. 

Sybups,  objections  to  use  of,  40,  340. 


Tachycardia,  paroxysmal,  506. 

Tachypnea,  in  acute  cardiac  dilatation, 
497. 

Talbot,  on  microscopical  examination  of 
stools,  35. 

Tapeworm.    See  Tenia. 

Tar,  therapeutic  use  of,  in  eczema,  723. 

Tartar-emetic,  objections  to  use  of,  in 
bronchopneumonia,  467;  in  acute  ca- 
tarrhal bronchitis,  467. 

Taste,  sense  of,  in  new-born  child,  22. 

Teachers,  necessity  for  knowledge  of 
child's  nervous  system  by,   6. 

Teeth,  care  of,  146;  Hutchinson's,  146, 
366;  imperfection  of,  in  sporadic  cre- 
tinism, 554;  permanent,  146;  syphili- 
tic, 365;   temporary,  144. 

Temperature,  of  bath  in  early  infancy, 
3;  of  bath  in  scarlet  fever,  329;  of 
cold  pack,  405;  of  incubator,  66;  of 
Priessnitz  applicator,  451;  of  sponge 
bath  in  illness,  45;  of  tub  bath  in 
illness,  45,  267;  of  warm  bath  in  as- 
phyxia neonatorum,  73;  of  warm  bath 
in  eclampsia,  682. 

Temperatitre  of  room,  in  acute  articu- 
lar rheumatism,  441;  in  bronchopneu- 
monia, 468;  in  acute  catarrhal  bron- 
chitis, 441 ;  in  acute  laryngitis,  443 ;  in 
lobar  pneumonia,  450;  in  measles, 
339;  in  acute  nephritis,  581;  in  scarlet 
fever,  329. 

Temperature,  range  of,  in  adenitis,  543 ; 
in  appendicitis,  225;  in  acute  articular 
rheumatism,  403;  in  brain  abscess, 
618;  in  bronchopneumonia,  457,  458; 
in  cholera  infantum,  192;  in  chorea, 
700;  in  cystopyelitis,  585;  in  diph- 
theria, 297;  in  empyema,  472;  in  acute 
endocarditis,  490;  in  enteric  infection, 
190;  in  erythema  infectiosum,  343; 
in  erythema  multiforme,  730;  in  acute 
gastri'*-  indigestion,  159 ;  in  acute  gas- 
tritis, 160;  in  acute  gastroduodenitis, 
165;  in  gonocoecus  vulvovaginitis, 
592;  in  hemophilia,  538;  in  Hodgkin's 


disease,  541;  in  Holt's  inanition  fever, 
88;  in  influenza,  309,  311;  in  acute  in- 
testinal indigestion,  184;  in  chronic  in- 
testinal indigestion,  199;  in  intestinal 
intussusception,  221;  in  acute  laryn- 
gitis, 430;  in  lobar  pneumonia,  445; 
in  lymph-node  tuberculosis,  383 ;  in 
malaria,  281;  in  mastoiditis,  717;  in 
measles,  uncomplicated,  336;  in  mea- 
sles, complicated  with  bronchopneumo- 
nia, 337,  338;  in  meningococcic  men- 
ingitis, 633 ;  in  mumps,  359 ;  in  myeli- 
tis, 653;  in  acute  nephritis,  577;  in 
otitis  media,.  714;  in  pericarditis,  510; 
in  peritonitis,  230;  in  pleurisy,  472; 
in  acute  anterior  poliomyelitis,  644; 
in  pseudoleukemia,  525;  in  purpura 
hemorrhagica,  533;  in  recurrent  vom- 
iting, 253;  in  retropharyngeal  abscess, 
428;  chronic  rheumatoid  arthritis, 
408;  in  acute  rhinitis,  412;  in  rubella, 
341;  in  scarlet  fever,  318;  in  sepsis  of 
the  newborn,  78;  in  septic  endocar- 
ditis, 494;  in  stomatitis  gangrenosa, 
153;  in  tetanus  neonatorum,  90;  in 
tetany,  689;  in  acute  follicular  ton- 
sillitis, 419;  in  tuberculous  broncho- 
pneumonia, 462;  in  tuberculous  menin- 
gitis, 627;  in  typhoid  fever,  269,  270, 
271,  272;  in  vaccinia,  352;  in  variola, 
346;  in  varicella,  355. 

Temperature,  subnormal,  in  congenital 
atelectasis,  74;  in  premature  infants, 
62;   in  sporadic  cretinism,  554,  555. 

Tenia,  211;  diagnosis  of,  213;  diflferen- 
tial  diagnosis  in,  211;  elliptica,  213; 
saginata,  211;  solium,  211;  sympto- 
matology of,  213;  treatment  of,  214; 
varieties  of,  211. 

Testicle,  undescended,  297. 

Tetanus,  antitoxin  of,  59;  transmission 
of,  by  vaccination,  353. 

Tetanus  neonatorum,  89;  treatment  of, 
90. 

Tetany,  686;  definition  of,  686;  differ- 
ential diagnosis  in,  689 ;  etiology  of, 
686;  pathology  of,  687;  symptomatol- 
ogy of,  687;  treatment  of,  689. 

Therapeutics  of  infancy  and  child- 
hood, 38. 

Thermogenic  centers,  activity  of,  in 
young  child,  26,  260;  loss  of  restraint 
over,  in  heat-stroke,  262;  situation  of, 
25. 

Thermoinhibitory  centers,  26;  in  pre- 
mature infant,  62. 

Thigh  friction.  See  Pseuclo masturba- 
tion. 


INDEX 


779 


Thompson's  solution  of  phosphorus, 
245. 

Thompson,  on  congenital  laryngismus 
stridulus,  437. 

Thread  worm.   See  Oxyuris  vermicularis. 

Throat  and  nose,  inspection  of,  in  ill- 
ness, 29;  daily  disinfection  of,  protec- 
tion against  endocarditis,  493. 

Thrush.     See  Stomatitis  aphthosa. 

Thumb-sucking,  703. 

Thymus  gland,  anatomy  of,  545;  asth- 
ma associated  with  enlargement  of, 
546;  enlargement  of,  in  status  lympha- 
ticus,  545,  657,  648;  excessive  activity 
of,  548;  function  of,  545;  hyperpla- 
sia of,  545;  surgical  treatment  for  en- 
largement of,  550;  X-ray  treatment 
for  enlargement  of,  548. 

Thyroid  gland,  absence  of,  557;  exces- 
sive activity  of,  557;  excessive  activ- 
ity of,  at  puberty,  17;  insuflScient  ac- 
tivity of,  555;  insufficient  activity  of, 
a  cause  of  enuresis,  599 ;  therapeutic 
use  of,  556. 

Thyroid  intoxication,  557;  treatment 
of,  558. 

Thyroid  therapy,  554. 

Tic.    See  Habit  spasm. 

Tinea  tonsurans,  733;  treatment  of, 
734. 

Tongue,  appearance  of,  in  scarlet  fever, 
321 ;  appearance  of,  in  typhoid  fever, 
272,  276;  ulceration  of,  in  whooping 
cough,  289;  wandering  rash  of;  See 
Geographical  tongue. 

Tongue-tie,  156. 

Tonsils,  diseased,  anatomy  involved  in, 
417;  association  of,  with  chorea,  701; 
association  of,  with  chronic  heart  dis- 
ease, 503;  association  of,  with  leuke- 
mia, 531 ;  association  of,  with  pavor 
nocturnus,  672,  675;  association  of, 
with  status  lymphaticus,  545,  547; 
danger  from,  to  health,  415;  micro- 
organisms present  in,  417;  operation 
for  removal  of,  421;  as  portals  of  in- 
fection, 418,  493;  removal  of,  a  pro- 
tection against  endocarditis,  493;  re- 
moval of,  a  protection  against  tubercu- 
losis, 395;  removal  of,  in  treatment  of 
acute  rhinitis,  414;  removal  of,  in 
treatment  of  chronic  rhinitis,  415. 

Tonsillitis,  acute  follicular,  419; 
differential  diagnosis  of,  420;  symp- 
tomatology of,  419;  treatment  of, 
222. 

Tonsillitis,  418;  accompanying  ade- 
noid disease,  425;  accompanying  acute 


articular  rheumatism,  404;  accompany- 
ing influenza,  310;  accompanying  acute 
anterior  poliomyelitis,  644;  diagnosis 
between,  and  diphtheria,  420;  differ- 
•  ential  diagnosis  of,  420;  acute  follicu- 
lar, 418;  preceding  laryngitis,  430; 
prognosis  of,  420;  recurrent  vomiting 
associated  with,  503;  acute  rhinitis  as- 
sociated with,  413;  treatment  of,  422; 
ulcero-membranous,  419. 

Tonsillar  hypertrophy,  chronic,  420; 
treatment  of,  424. 

Torticollis,  intermittent  spasmodic, 
283. 

Toxemia,  intestinal,  in  causation  of 
fever,  261,  265;  constipation  associa- 
ted with,  in  typhoid  fever,  272;  effects 
of,  in  diphtheria,  297;  effects  of,  in 
influenza,  310;  effects  of,  in  typhoid 
fever,  269. 

Toxic  nephritis.    See  Nephritis. 

Tracheotomy,  in  edema  of  larynx,  435; 
for  relief  of  foreign  bodies  in  larynx, 
trachea,  or  bronchi,  437;  in  laryngeal 
diphtheria,  305;  in  acute  rhinitis  in 
infants,  415;  in  variola,  349. 

Transfusion  of  blood,  in  hemorrhage  of 
new-bom,   84. 

Trichuris  trichiura,  217. 

Tricuspid  regurgitation,  502. 

Trudeau,  on  treatment  of  localized 
forms  of  tuberculosis,   58. 

Trousseau,  on  causes  of  tetany,  687. 

Trousseau's  symptom,  688,  689. 

Tuberculides  of  skin,  384. 

Tuberculin  reactions,  conjunctival, 
385;  in  diagnosis  of  concealed  lymph- 
node  tuberculosis,  385;  in  differential 
diagnosis  between  tuberculosis  and 
Hodgkin's  disease,  542;  skin,  36; 
value  of,  at  different  ages,  400. 

Tubercle  bacillus,  bacteriology  of,  373; 
in  pleurisy,  470;  in  cystopyelitis,  584. 

Tuberculosis,  373;  of  bones  and  joints, 
381,  401;  climate  in  treatment  of,  396; 
contagiousness  of,  373;  contraindica- 
tion to  nursing  infant,  112;  cough  in, 
383,  389;  diagnosis  between,  and  early 
hereditary  syphilis,  367;  diagnosis  be- 
tween, and  Hodgkin's  disease,  541; 
diagnosis  between,  and  malaria,  284; 
diagnosis  between  acute  miliary,  and 
typhoid  fever,  275;  diet  in,  397';  drugs 
used  in  treatment  of,  398;  etiology  of, 
373;  exercise  in  treatment  of,  398;  ex- 
posure to,  374;  fresh  air  in  treatment 
of,  396;  guaiacol  inunctions  in  treat- 
ment of,  398;  heredity  in  transmission 


780 


INDEX 


of,  375;  hydrocephalus  due  to,  619; 
acute  infectious  diseases  a  predispos- 
ing cause  of,  375;  influenza  a  cause 
of,  315;  influenza  complicated  by,  312; 
intestinal  form  of,  227,  380;  of  kid- 
ney, 595;  of  lungs  in  older  children, 
388,  401;  lymph-node  form  of,  377, 
382;  measles  complicated  by,  337; 
medical  treatment  of,  398;  general  mi- 
liary, 381;  general  miliary  in  infants, 
387;  microorganism  in,  373;  obscure 
fever  due  to,  364;  pathology  of,  377; 
peritonitis  due  to,  381,  401;  physical 
signs  in,  384;  pleural  form  of,  379; 
portals  of  infection  in,  374;  poverty  a 
predisposing  cause  of,  375;  prophylaxis 
of,  393;  pulmonary  form  of,  379;  re- 
moval of  cervical  glands  in,  400;  rest 
in  treatment  of,  398;  school  infection 
in  transmission  of,  376;  as  sequel  to 
lobar  pneumonia,  448;  of  serous  mem- 
branes, 373;  of  skin,  384;  sources  of 
infection  in,  373;  sputum  a  source  of 
danger  in,  373;  symptomatology  of, 
382;  tests  for,  36;  treatment  of,  395; 
vaccination  not  a  means  of  transmis- 
sion in,  355;  whooping-cough  compli- 
cated by,  288,  289,   290. 

Tuberculosis  op  lymph-nodes,  cervical 
form  of,  400;  cervical  adenitis  in, 
386;  diagnosis  of,  385;  diagnosis  be- 
tween, and  Hodgkin's  disease,  542; 
dyspnea  in,  382;  dwarfishness  in,  383; 
enlargement  of  external  lymph-nodes 
in,  384;  gastrointestinal  disturbance 
in,  383;  groups  of  glands  involved  in, 
378 ;  malnutrition  in,  383 ;  menstrual 
irregularities  in,  383;  neurotic  disease 
suggestive  of,  382;  pain  in  side  in, 
382;  pathology  of,  377;  physical  signs 
of,  384;  pressure  signs  of,  385;  pro- 
gressive failure  of  health  in,  382;  ra- 
diographic examination  in,  385;  re- 
moval of  glands  in,  400;  respiratory 
symptoms  in,  383;  simple  anemia  sug- 
gestive of,  382;  skin  manifestations 
of,  384;  temperature  in,  383;  tubercu- 
lin reactions  in,  385. 

Tuberculous  bronchopneumonia,  387; 
treatment  of,  401. 

Tuberculous  meningitis.  See  Menin- 
gitis, tuberculous. 

Turpentine,  oil  of,  inhalations  of,  in 
treatment  of  acute  rhinitis,  414. 

Typhoid  fever,  267;  abdominal  symp- 
toms in,  271 ;  antityphoid  inoculation 
in,  276 ;  bacillus  of,  267 ;  baths  in  treat- 
ment of,  277;   blood  changes  in,  273; 


"carriers"  of,  267,  268;  complica- 
tions of,  274;  definition  of,  267;  dif- 
ferential diagnosis  in,  275;  diet  in, 
276;  drugs  used  in  treatment  of,  277, 
278;  epistaxis  in,  273;  etiology  of, 
267;  exanthem  in,  271;  "carriers"  of, 
267,  268;  in  fetus,  269;  incubation 
period  in,  269;  intestinal  hemorrhage 
in,  272,  278;  meningitis  in,  640; 
mortality  in,  275;  method  of  infec- 
tion in,  268;  nervous  system  in,  272, 
278;  in  new-born,  269;  obscure  fever 
due  to,  265;  pathology  of,  268;  perfo- 
ration of  intestine  in,  272;  prophy- 
laxis of,  275;  prognosis  of,  275;  re- 
lapses in,  274;  removal  of  patient  in, 
279;  respiratory  symptoms  in,  273; 
sources  of  infection  in,  268;  splenic 
enlargement  in,  271;  symptomatology 
of,  269;  temperature  changes  in,  270; 
tongue  in,  272;  treatment  of,  276; 
urine  findings  in,  273;  Widal  reaction 
in  diagnosis  of,  273. 

Typhoid  vaccine,  therapeutic  use  of,  59. 

Tyrotoxicon,  symptom  group  produced 
by,  176. 

U 

Ulcer  op  stomach,  164. 

Umbilical  cord,  care  of,  3. 

Umbilicus,  diseases  of,  84;  gangrene, 
85;  hemorrhage,  85;  hernia,  86;  in- 
fection of  stump,  84;   vegetations,  84. 

Unguentum  crede,  therapeutic  use  of, 
43;  in  adenitis,  544;  in  dermatitis  ex- 
foliativa of  new-born,  80 ;  in  erysipe- 
las of  new-born,  82;  in  measles,  340; 
in  acute  infective  myelitis,  657;  in 
septicemia  of  diphtheria,  307;  in  sep- 
ticemia of  scarlet  fever,  331;  in  tu- 
berculous peritonitis,  401;  in  ulcerative 
endocarditis,  494. 

Upper  arm  paralysis,  99. 

Urea,  amount  of,  in  infancy,  561;  reten- 
tion of,  in  acute  nephritis,  577. 

Uremia,  presence  of,  in  cystic  degenera- 
tion of  kidney,  589;  in  acute  nephri- 
tis, 576;  in  tumor  of  the  kidney,  588; 
eclampsia  caused  by,  680. 

Urethritis,  in  male  child,  595. 

Uric  acid,  "infarcts,"  561. 

Ueic  acid,  in  urine,  in  infancy,  561;  in 
acute  nephritis,  577;  in  whooping- 
cough,  290. 

Urine,  acidity  of,  a  cause  of  pseudo-mas- 
turbation, 607,  609 ;  effect  of  uric  acid 
upon,  561 ;  examination  of,  in  illness, 
34;    fluctuations   in    amount    of,    560; 


INDEX 


781 


frequency  in  passage  of,  561;  incon- 
tinence of,  561;  method  of  collecting 
for  examination  in  infant,  559;  reten- 
tion of,  in  myelitis,  656;  suppression 
of,  in  absence  of  kidney,  577;  suppres- 
sion of,  in  acute  nephritis,  577 ;  sup- 
pression of,  in  new-born,  561;  suppres- 
sion of,  in  young  child,  560. 

Urogenital  organs,  embryonic  develop- 
ment of,  604;  nerve  supply  of,  605; 
physiological  evolution  of,  605. 

Ukotropin,  therapeutic  use  of,  in  cys- 
topyelitis,  587;  in  enuresis,  603;  in 
mumps,  360;  in  acute  anterior  polio- 
myelitis, 651. 

Urticaria,  726;  accompanying  asthma, 
713;  characteristic  of,  726;  definition 
of,  726;  diet  in,  728;  etiology  of,  726; 
accompanying  Henoch 's  purpura,  534 ; 
mucous  membranes  in,  727;  prognosis 
in,  727 ;  accompanying  purpura  rheu- 
matica,  535;  symptomatology  of,  726; 
treatment  of,  727. 

Uvula,  elongated,  155. 


Vaccinia,  349 ;  clinical  manifestations  of, 
351;  complications  of,  353;  definition 
of,  349;  incubation  period  of,  349; 
temperature  in,  351;  secondary  rash 
in,  352. 

Vaccination,  discovery  of,  349;  immun- 
ity, conferred  by,  353;  technique  of, 
350;  treatment  of  wound,  354;  virus 
used  in,  350. 

Vaccine  therapy,  55 ;  antiserums  in,  59 ; 
autogenous  vaccines  in,  57;  bacterial 
vaccines  in,  56;  clinical  reaction  in, 
56;  coll  vaccines  in,  59;  in  cystopye- 
litis,  587;  discovery  of,  55;  in  chronic 
empyema,  481;  in  furunculosis,  729; 
gonococcus  vaccine  in,  58;  in  gono- 
coccus  vulvovaginitis,  594;  Koch's  tu- 
berculin in,  58;  in  lobar  pneumonia, 
452 ;  opsonic  index  in,  56 ;  pneumococcus 
vaccine  in,  58;  rules  for  use  of,  56; 
in  scarlet  fever,  332;  staphylococcus 
vaccine  in,  57;  streptococcus  vaccine 
in,  58;  therapeutic  indications  for,  57; 
typhoid  vaccines  in,  59;  in  ulcerative 
endocarditis,  494;  in  whooping-cough, 
294;  without  opsonic  index,  56. 

Valentine's  meat  juice,  277. 

Valerian,  therapeutic  use  of,  in  asthma, 
708 ;  in  functional  heart  disorders,  508. 

Varicella,  354;  blood  changes  in,  356; 
complications    in,    356;    definition    of, 


356;  diagnosis  of,  354;  diet  in,  357; 
drugs  used  in  treatment  of,  356;  en- 
anthem  stage  in,  355;  etiology  of,  354; 
exanthem  stage  in,  356;  immunity  con- 
ferred by,  357;  incubation  period  in, 
355;  microorganisms  present  in,  354; 
prophylaxis  in,  357;  quarantine  in, 
357;  symptomatology  of,  355;  temper- 
ature changes  in,  355;  treatment  of, 
357. 

Variola,  345;  blood  changes  in,  347; 
clinical  forms  of,  347;  confluent  form 
of,  347;  contagious  period  of,  345; 
definition  of,  345;  diagnosis  of,  348; 
diet  in,  348;  drugs  used  in  treatment 
of,  348,  349;  enanthem  stage  in,  346; 
etiology  of,  345;  exanthem  stage  of, 
346;  hemorrhagic  form  of,  347;  im- 
munity conferred  by,  345;  incubation 
period  of,  345 ;  invasion  stage  of,  345 ; 
microorganisms  present  in,  345;  mor- 
tality from,  350;  prophylaxis  of,  348; 
purpuric  form  of,  348;  quarantine  in, 
348;  red  light  treatment  of,  349; 
symptomatology  in,  345;  temperature 
changes  in,  346;  transmission  of,  345; 
treatment  of,  348;  urine  findings  in, 
347;  vaccination  as  protection  against, 
349. 

Vasomotor  paralysis.  See  Splanchnic 
paralysis. 

Vaughn,  on  contaminated  food,  176. 

Vegetations  of  the  umbilicus,  84. 

Venesection,  therapeutic  use  of,  in 
acute  cardiac  dilatation,  498;  in  ec- 
lampsia, 683;   in  acute  nephritis,  580. 

Veronal,  therapeutic  use  of,  in  chorea, 
701;  in  meningococcic  meningitis,  638; 
in  multiple  neuritis,  664;  in  acute  ne- 
phritis, 581. 

Villemin,  operation  by,  for  obstruction 
of  esophagus,  158. 

Vincent's  angina.  See  Ulceromembran- 
ous to7isillitis. 

Vincent's  bacillus,  419. 

Vincent's  spirillum.  See  Vincent's 
bacillus. 

ViPOND,  isolation  by,  of  bacillus  produc- 
ing scarlet  fever,  317. 

Vleminckx's  solution,  formula  for, 
729. 

Vomiting,  as  symptom,  of  brain  abscess, 
618;  of  brain  tumor,  618;  of  enteric 
infection,  191;  of  intestinal  intussus- 
ception, 220 ;  in  lobar  pneumonia,  443 ; 
in  malaria,  284;  in  meningococcic  men- 
ingitis, 632;  in  purulent  meningitis, 
639;    in   recurrent   vomiting,    283;    in 


782 


INDEX 


scarlet  fever,  318;  in  tuberculous  men- 
ingitis, 627. 

Vomiting,  recurrent.  See  Eccurrent 
vomiting. 

Von  Jaksch,  discovery  of  pseudoleu- 
kemia by,  524. 

Von  Jaksch 's  disease.  See  Pseudo- 
leukemia. 

Von  Noorden,  on  factors  in  formation  of 
oxybutyric  acid,   565. 

Von  Pirquet,  on  predisposing  causes  of 
tetany,  687;  on  scarification  tuberculin 
test  in  diagnosis  of  lymph-node  tuber- 
culosis, 385;  on  skin  reaction  in  tuber- 
culous meningitis,  628,  629. 

Von  Pirquet 's  test,  for  tuberculosis, 
35. 

Vovaird,  investigation  by,  on  primary 
splenomegaly,  552. 

Vulvovaginitis,  gonorrheal,  591;  com- 
plications of,  592;  definition  of,  591; 
epidemics  of,  591;  etiology  of,  591; 
frequency  of,  595;  microorganisms  in, 
592;  prognosis  of,  593;  prophylaxis 
of,  593;  sources  of  infection  in,  591; 
symptomatology  of,  592;  treatment  of, 
593;  vaccine  therapy  in,  594. 

Vulvovaginitis,  simple,  595;  associa- 
tion of,  with  pseudo-masturbation, 
608. 

Vulva,  diphtheria  of,  299. 


W 


Walkee-Gordon  laboratories,  141. 

Walker-Gordon  milk,  118. 

Wandering  rash  of  the  tongue.  See 
Geographical   tongue. 

Warthin,  on  edema  of  thymus  gland, 
545;  on  weight  of  thymus  gland  in 
health  and  disease,  545. 

Wassermann-Neisser  reaction,  362, 
368. 

Water,  drinking,  in  causation  of  ty- 
phoid fever,  268,  275;  importance  of, 
in  infant  diet,  105;  importance  of,  to 
new-born,  113. 

Water,  drinking,  therapeutic  use  of,  47; 
in  influenza,  313;  in  lobar  pneumonia, 
451 ;  in  multiple  neuritis,  663 ;  in 
chronic  nephritis,  583 ;  in  orthostatic 
albuminuria,  571;  in  purpura,  536;  in 
typhoid  fever,  277. 

Weaning,  116. 

Weichselbaum,  discovery  by,  of  special 
organism  of  meningococeic  meningitis, 
631. 

Weight,   comparative   ratio   of,  in   boys 


and  girls,  16,  17;  gain  in,  during  first 
year  of  life,  15 ;  gain  in,  after  first 
year  of  life,  15;  importance  of  ascer- 
taining, at  first  examination  in  illness, 
29;  importance  of,  to  health,  in  infan- 
cy and  childhood,  13;  premature  in- 
fants deficient  in,  65;  relation  of,  to 
physical  condition,  7;  relation  of,  to 
skin  surface  of  body,  26;  significance 
of  failure  to  gain  in,  14. 

Welsh,  E.  J.,  method  of  injecting  blood 
serum  introduced  by,  84. 

Wet  nurse,  advantages  of,  117;  in  gas- 
trointestinal disorders,  74;  in  enteric 
infection,  194;  for  premature  infant, 
68;  in  pseudo-leukemia,  526. 

Wet  nurse,  danger  to,  of  syphilitic  in- 
fant, 369;   of  tuberculous  infant,  394. 

Whey,  as  artificial  food  in  chronic  intes- 
tinal indigestion,  201;  proteins  con- 
tained in,  101. 

Whiskey,  therapeutic  use  of,  in  broncho- 
pneumonia, 466;  in  acute  cardiac  dila- 
tation, 498;  in  diphtheria,  307;  in  en- 
teric infection,  193;  in  lobar  pneu- 
monia, 450,  453 ;  in  new-born,  73,  81 ; 
in  acute  pericarditis,  513;  in  pleurisy, 
478;  in  acute  anterior  poliomyelitis, 
651;  in  scarlet  fever,  329;  in  typhoid 
fever,  277,  278;  in  variola,  349. 

Whooping-cough,  287;  bacillus  of,  287; 
blood  changes  in,  289;  catarrhal  stage 
in,  288;  complications  of,  290;  con- 
tagious period  in,  288;  course  of,  290; 
acute  catarrhal  dilatation  caused  by, 
496,  497;  danger  of,  to  infants,  6; 
danger  of,  to  tuberculous  children, 
395;  definition  of,  287;  diagnosis  of, 
290;  diet  in,  292;  drugs  used  in  treat- 
ment of,  293;  etiology,  287;  incuba- 
tion period  of,  288;  measles  complica- 
ted by,  338 ;  medical  treatment  of, 
293 ;  prognosis  of,  291 ;  prophylaxis  in, 
291;  psychic  treatment  of,  292;  spas- 
modic stage  of,  288;  symptomatology 
of,  288;  temperature  changes  in,  288; 
treatment  of,  291;  urine  findings  in, 
290. 

Wickman,  on  mortality  in  acute  anterior 
poliomyelitis,  650;  on  types  of  acute 
anterior  poliomyelitis,   644. 

WiDAL  reaction.  See  Gruber-Widal  re- 
action. 

Williams,  on  thyroid  insufficiency  as  a 
cause  of  enuresis,  599;  on  thyroid  ther- 
apy in  enuresis,  603. 

Winckel's  disease.  See  Epidemic  he- 
moglobinuria. 


INDEX  783 

WiXTEKGREEX,  OIL  OF,  therapeutic  use  of,  Z 

by   inunction,   42,   43;    in   acute   folli- 
cular tonsillitis,  422.  Zinc,  multiple  neuritis  due  to  poisoning 
WoLLSTEix,  observations  by,  on  bacillus  by>  661. 

pertussis,  287.  Zinc  oxid,  therapeutic  use  of,  internally 

Wright,  E.  A.,  on  antityphoid  inocula-  in  tuberculous  diarrhea,  400. 

tion,  276;  on  "opsonins,"  55,  56.  Zinc  oxid,  ointment  of,  therapeutic  use 

"Wrist-drop  "  662.  of,  in  eczema,  723;  in  erythema  multi- 

forme, 730;  in  syphilis,  373. 
X  Zinc  stearate,  therapeutic  use  of,  in  ec- 

zema, 723;  in  pemphigus  neonatorum, 
X-RAY.     See  Bontgen  rays.  733. 


0) 


51 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


NOV  2  2  1954 


BIOMEDMAY  2 

MAY29I 
BIOMEO  o£(; 

oec 


^Oflssji 


179 

REC'D 

15 '82 


Form  L9-42m-8,'49  (B5573)444 


..at?at..  I : 


r 

1 

58  00374  5816 


i«mi£S12Kl?^  IJeflAflY  FAOirrv 


A     000  356  143     8 


